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Inspection Summary


Overall summary & rating

Updated 16 November 2020

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Teladoc Health UK. We undertook this inspection in response to concerns we had received.

Teladoc Health UK provides an online GP consultation, treatment and prescribing service for a limited number of medical conditions to patients in England.

Our key findings were:

  • The service had systems to record, investigate and monitor significant events and safety alerts. However, we found that not all incidents had been recorded and not all staff were clear about the significant event policy or process.
  • 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.
  • The provider carried out checks to ensure consultations by GPs met the expected service standards.
  • Prescribing was in line with national guidance, and patients were told about the risks associated with any medicines prescribed.
  • Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Patients could access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on staff development, learning and improvement at all levels of the organisation. Staff felt supported, valued and appreciated.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue making improvements to the clinical system and ensure patient information about previous consultations is available in an immediately accessible way.
  • Continue to improve the complaints process and information for patients.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Updated 16 November 2020

Keeping people safe and safeguarded from abuse

  • All staff had received training to the appropriate level on safeguarding children and vulnerable adults and knew how to spot the signs of abuse . All staff had access to the safeguarding policies. The safeguarding policy made it clear that concerns should be reported to the local authority where the patient lived, and included contact details for these authorities. It was a requirement for all GPs working for the service to provide evidence of up to date safeguarding training certification.

  • There was an identity verification policy in place and security measures to make sure that the identity of a client was confirmed. For new clients, the service used an independent identity verification company as the mandatory first stage of registration. Once confirmed, authentication questions were then set up to complete the registration with Teladoc. These were then used to verify the client for all future contacts with the service. The only exception to this was in emergency situations to ensure any necessary assessment and action could be undertaken by a clinician. All patients received terms and conditions of service at the point of registration.

  • The provider offered services to children under the age of 18 years old. The service had systems in place to assure that an adult accompanying a child had both completed the identity verification process, and evidenced parental responsibility.

Monitoring health & safety and responding to risks

  • The providers headquarters were located within modern offices which housed the IT system. Patients were not treated on the premises as GPs carried out the online consultations remotely; usually from their home. At the time of our inspection, the provider had recently re-opened their office following a period of closure due the infectious disease COVID-19 pandemic. All staff based in the premises had received training in health and safety. This included additional information and access to webinars about COVID-19 to prepare for their return to the workplace, and ongoing infection control requirements. The provider had brought in a number of new measures to keep people safe and reduce the risk of infection. For example, they developed a self-screening protocol, and an attestation form which was mandatory for daily completion. This was used to record that staff had declared they had no COVID-19 symptoms at the time of completion. They also issued each member of office staff with their own ‘return to work’ pack, which included a thermometer and personal items such as a cup and their own cutlery.

  • 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 the any contact or consultation and for managing test results or referrals. The service was not intended for use by patients with either long term conditions or as an emergency service and this was made clear to patients. The service had clear policies and procedures that provided information about how to recognise a high risk case and what to do. Non clinical staff had received additional training on how to recognise a medical emergency or symptoms of a severe infection, such as sepsis. We saw that a GP clinical lead had developed and presented a training webinar for all staff on how to identify medical emergencies, which included information on how to escalate and how to record. They also received guidance on how to identify mental health emergencies. 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. Staff told us this information was easily accessible and they felt well supported.

  • 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 further attention. Consultations identified as a higher risk or immediate risk were sent to the medical directors to be assessed and actioned as appropriate. Risks were discussed at weekly clinical meetings. 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 these topics had been discussed.

Staffing and Recruitment

  • Staff all told us they felt there were enough staff, including GPs, to meet the demands for the service. There was a rota for the GPs who were given weekly fixed shifts. There was a rota for an on-call duty doctor and medical director, who were available to provide any necessary support to the GPs during consultations or to the customer services team. The clinical leads would complete consultations if necessary. Staff told us they were confident that support was available whenever needed.

  • 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, proof of identification 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 registered with the General Medical Council (GMC) and be on the NHS National Performers list (The National Performers List is of approved GPs, opticians and dentists who satisfy a range of criteria for working in the NHS).

  • We saw the recruitment policy, which described all aspects of the induction period and an induction checklist for newly recruited GPs, 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 five 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

  • The provider monitored prescribing to ensure it was evidence based. If a medicine was deemed necessary following a consultation, the GPs could issue a private prescription to patients. The provider had risk-assessed the medicines it was appropriate to prescribe and their policy was not to prescribe medicines subject to misuse.  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. 

  • 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.

  • In exceptional cases the service would prescribe for long term conditions that need to be monitored.  The GPs requested information from the patient to confirm previous prescriptions and recent test results.  We were told that during the consultation the GP would discuss how the patient would obtain prescriptions in future, and those without an NHS GP were encouraged to register with a private GP for face to face services. They did not provide a repeat prescription service, but would prescribe up to three times in a year if it was safe to do so and the patient was not able to obtain a prescription from their usual doctor.  We saw an example where a patient who was temporarily in the UK had been prescribed medicine for high blood pressure. We saw appropriate assurance had been gained, including the patients current blood pressure reading and evidence of previously prescribed medicine.

  • The service encouraged good antimicrobial stewardship by prescribing in line with national guidance. The service did not prescribe unlicensed medicines or 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 listed on their licence is called unlicensed use and is a higher risk because less information is available about the benefits and potential risks).

  • We were advised that patients could choose a pharmacy where they would like their prescription dispensed. The prescription could be sent to a pharmacy to be dispensed and delivered direct to the patient or to their preferred local pharmacy for collection by the patient.

Management and learning from safety incidents and alerts

  • The service had a system in place to receive, review and record patient safety alerts.  They distributed relevant alerts to the GPs.

  • There were systems in place for identifying, investigating and learning from incidents relating to the safety of patients and staff members. We saw one significant event that had been fully investigated and discussed. There were thorough records of this incident and the actions completed to improve processes. This involved a GP making an inappropriate referral to another Teladoc service. The provider had responded by communicating information about the scope of service to all staff, the development of a risk assessment module for all GPs and an audit of cases referred to the other service. We saw these actions had been recorded as completed.

  • However, although there was a written policy and procedure, not all staff could describe what a significant event was or the reporting process. We also found that records of significant events were not always complete. For example, staff told us about data breaches that had occurred. We saw two incidents of a data breach discussed in a clinical meeting in November 2019. These involved one incident where patient notes had been sent to the wrong patient, and another where notes had been incorrectly sent to a Teladoc client. Within the minutes, we saw the provider had taken steps to investigate and they planned a review of processes relating to sharing of notes. We did not see any notes to demonstrate the requirements of duty of candour had been complied with for those patients. This includes explaining to the patient what went wrong, offering an apology and advising them of any action taken.

  • Following our inspection, the provider demonstrated they took our concerns seriously. They acted promptly and sent us information to demonstrate they had taken steps to improve their processes. They shared a new training module on significant events with us, which had been rolled out to all staff. This included definitions and details on how to report significant events, with an assessment for understanding. They were also reviewing their significant events processes.
  • Additionally, the provider told us they completed a thorough investigation into the circumstances of data breaches. They sent us their reviewed and updated data breach response protocol, which was also aligned to their Duty of Candour. They told us that their review processes have been completed in accordance with advice from their Data Protection Officer.

Effective

Updated 16 November 2020

Assessment and treatment

  • During interviews and clinical records review with GPs and leaders at the service, we saw and were told 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 were told that each consultation lasted for approximately 20 minutes. If the GP had not reached a satisfactory conclusion there was a system in place where they could contact the patient again. GPs that we spoke with told us they could take more time if needed, for example to ensure the patients’ medical history was obtained in detail.

  • Patients could complete an online form to request a consultation, which included their past medical history and reason for the request. The service had developed a set template for clinicians to complete during the consultation, which 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 four consultation records. We saw that adequate notes were recorded, and the GPs had immediate access to all previous consultation notes within the past three months. The service leaders explained they had moved over to a new system in June 2020 and although the previous consultation notes were available on the previous system, they were in the process of moving them over. They told us that improvement work was continuing on the system, including to make sure clinicians had access to all notes in an immediately accessible way.

  • The GPs providing the service were aware of both the strengths (speed, convenience, choice of time) and the limitations (inability to perform physical examination) of working remotely from patients. They worked carefully to maximise the benefits and minimise the risks for patients. If a patient needed further examination, they were directed to an appropriate agency. If the provider could not deal with the patient’s request, this was explained to the patient and a record kept of the decision.

  • GPs were able forward consultation notes to the patient if they had access to the Teladoc mobile application. They included links to any relevant information and advice to reinforce what was discussed. We saw an example of an online record to demonstrate that a patient could access and view all of their received consultation notes.

Quality improvement

  • The provider collected and monitored information on patients’ care and treatment outcomes.

  • We saw evidence of recent reports that had been generated to monitor service. For example, in February 2020 we saw there had been 526 consultations, 73 prescriptions and 50 referrals made. The provider used information about patients’ outcomes to make improvements.

  • The provider took part in quality improvement activity, for example audits, reviews of consultations and prescribing trends. The provider sent us evidence of several audits undertaken, which had resulted in changes to clinical management and prescribing, in line with local and national guidance. For example, an audit on the assessment and management of urinary tract infections (UTIs), which looked at whether common causes had been explored or excluded in line with national guidance. This was a two cycle audit that had been completed in December 2019 and July 2020. The first audit included 20 cases where a prescription had been issued. Recommendations were made, including that the findings be shared with all GPs and each patient should be issued with an information sheet. The next audit found improvement in all areas, for example the information sheet was documented in 90% of cases. However, there were some additional issues including prescribing errors. Further recommendations had been made to improve the assessment and management of UTIs.

  • The provider also carried out audits of consultation notes shortly after a GP had started in the role and at regular intervals thereafter. The provider sent us 22 examples of these post start reviews, which took place after the GP had conducted 15 consultations. We reviewed five of these and saw they included a conversation with the GP, a review of consultation notes, prescribing and follow up. We also saw that actions were agreed with the GP for improvement and development where appropriate.

  • We were also provided with evidence of five quality checks that had been completed for customer services staff. We saw that a standard checklist was used to assess compliance. The results were mostly positive and where improvements were required, these were shared individually with staff within one to one meetings.

Staff training

  • All staff completed induction training which included safeguarding, information governance, and fire safety. Staff also completed other training on a regular basis. The provider used an online training provider and they maintained a training matrix, which identified when training was due. Many staff members commented that they felt actively encouraged to develop and improve, for example all staff had access to the “Teladoc university” which housed training modules. Staff could choose any module they wished to complete. Staff we spoke with were positive about working at the service and felt their manager genuinely wanted to identify their skills and help them reach their goals.

  • The GPs registered with the service received specific induction training prior to treating patients. An induction log was held in each staff file and signed off when completed. Supporting material was available to all staff. When any organisational changes were made, the provider sent information via email and also posted relevant news onto the communication platform. The staff we spoke with told us they received excellent support if there were any technical issues or queries and could easily access policies.

  • Non clinical staff received regular support, including one to one meetings with their line manager and an annual appraisal. Staff we spoke with told us they felt this was a very positive process. All the GPs were required to have completed their own NHS appraisal before being considered eligible at recruitment stage. The provider was in the process of setting up regular internal appraisals for their GPs.

Coordinating patient care and information sharing

  • Before providing treatment, GPs 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 upon registration with the service and each occasion they used the service. The administrative team sent out consultation notes to the relevant NHS GPs during each night shift.

  • 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, those for the treatment of long term conditions such as asthma.

  • If a referral was required, GPs entered the referral information onto the computer system, including where the patient wanted to attend. The GP then sent a task to a dedicated administration team. There was a policy in place to check up on referrals to ensure these were received and processed. This included a tracking spreadsheet to monitor referrals to ensure their completion.

  • The service monitored the appropriateness of referrals/follow ups from test results to improve patient outcomes. For example, we saw an audit completed in December 2019. This looked at whether the referrals within that month had been justified, and whether the diagnosis could have been improved if further clinical tests had been conducted. There had been 579 cases recorded, with 35 referrals to other services made (6%). The majority of these referrals were for muscular skeletal conditions relating to muscles, joints and bones. All referrals were deemed to be appropriate. The audit identified 15 cases where primary care testing would have been appropriate (43%) and may have reduced the referrals or enhanced the diagnosis. Recommendations were made for improvements, including the possibility of organising primary care investigations. The audit was shared with clinicians.

Caring

Updated 16 November 2020

Responsive

Updated 16 November 2020

Responding to and meeting patients’ needs

  • Consultations were available 24 hours a day, seven days a week. The provider made it clear to patients what the limitations of the service were, although we noted this was not published on the provider’s website. 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.

  • Any prescriptions issued were sent within the UK to a pharmacy of the patient’s choice, or to a pharmacy which could dispense the prescription and deliver direct to the patient.

  • Patients could request a consultation with a GP by telephone or via the mobile application. They were sent an acknowledgement email, which we saw contained key details about the service such as the identity verification process and limitations of the service. Consultations could be booked for a specific time slot, or the same day where they would be contacted by a GP within two hours. During our inspection we looked at the live patient waiting lists. We saw there were two lists, one for clinical triage and one for requested consultations, where it had been deemed safe for the patient to wait. There were no patients on the triage list, as those appearing were promptly dealt with. For consultation requests, we saw a mix of patients that had asked for ‘on the day’ or allocated time. We saw there were a total of 24 patients on the list, and the longest a patient had been waiting for an ‘on the day’ appointment was one hour. Staff told us that in the event that patients were waiting over two hours, emails would be sent out to let them know the service was running late. Staff told us the only time this had happened was during the peak of COVID-19 (April 2020).

Tackling inequity and promoting equality

  • The provider offered consultations to any client who requested the service, and did not discriminate against any population group.

  • The provider told us they had a strong organisational commitment towards ensuring that there was equality and inclusion across the workforce. Comments from staff aligned with this view, and provided examples such as a dedicated channel on their communication platform for sharing ideas or concerns.

  • Patients could choose either a male or female GP or one that spoke a specific language. A diverse range of staff were employed, including that there were 15 languages spoken amongst the team. If a language barrier existed, then interpretation services were utilised for consultations. Although the service did not have built-in assistive technology aids, they told us they would always try to facilitate access for persons with a disability.

Managing complaints

  • The provider actively encouraged feedback from patients. Comments could be provided through the Teladoc mobile application, a post consultation survey sent to all patients, the website or via email.

  • The provider had developed a complaints policy and procedure. The complaints policy detailed the timescales for dealing with the complaint and the responsible person. 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 any feedback or complaints made to the service were recorded. There had been one formal complaint. The provider was able to demonstrate that the complaints or expressions of dissatisfaction 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.

  • We noted that the only information available to patients about how to make a formal complaint was within a section of their terms and conditions. However, the information within this section did not always align with the provider’s complaints policy, for example the timescales for an acknowledgement and formal response differed and the method of contact. The provider told us they had recently appointed a staff member to lead on quality assurance, including complaints management. They were in the process of updating their policy and processes. Following our inspection, the provider demonstrated they took our concerns seriously. They shared with us a new complaints leaflet that clearly described how to complain and the timescales for a response. They had also created a leaflet for internal staff about the complaints process.

Well-led

Updated 16 November 2020

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 year. We saw their mission was to transform how people access healthcare around the world. They wanted to offer convenient access to high-quality care, with better outcomes and better value for 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 easily accessible to all staff. These were reviewed annually and updated when necessary.

There were a variety of daily, weekly and monthly checks in place to monitor the performance of the service. These included random spot checks for consultations to ensure care was delivered in line with the provider’s guidelines. The information from these checks was used to produce a clinical weekly team report that was discussed at weekly team meetings. This, in conjunction with regular meetings, ensured a comprehensive understanding of the performance of the service was maintained.

There was strong collaboration, team-working and support across all functions of the service. There was a common focus on improving the quality and outcomes of care and people’s experiences of service.

There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. However, we found that the policies and procedures for managing significant events were not yet embedded. This meant the provider was not able to maintain an accurate overview of safety and risk. However, the provider took immediate action to respond to our concerns in relation to this.

Leadership, values and culture

The clinical director, medical director and general manager had overall responsibility for the day to day operation of the service. They were in daily contact with their management team, including clinical leads who had responsibility for clinical issues arising and the performance of GPs. The management team covered medical, technological and sales expertise. The management team communicated regularly with each other and all staff via email, or using their communication platform.

The provider acknowledged their current challenges, particularly as a relatively new company within the UK. They were honest about their areas for improvement and described how they had dealt with issues, especially during their first year. The described how they had responded to the COVID-19 pandemic and how this had been a learning experience, that demonstrated their ability to adapt. For example, they had recently recruited a number of new GPs and customer services staff, due to the increased demand caused by COVID-19, and had managed this process quickly yet safely.

The service had an open and transparent culture. We were told that if there were unexpected or unintended safety incidents, the service would give affected patients reasonable support, truthful information and a verbal and written apology. This was supported by an operational policy.

The provider told us the well-being of staff was a priority, to enable them to provide good quality care for patients. Staff we spoke with were extremely positive about working for the service, they felt valued, supported and told us the leaders were always visible. Many staff told us they appreciated the friendly style of the leadership team.

The provider described how they had supported the well-being of their staff during the COVID-19 period, who all worked remotely once the office was temporarily closed. For example, they provided all staff with free access to their mental health service, along with webinars or leaflets on well-being and nutrition. They had also provided staff with shopping vouchers to assist them financially during the crisis. The management team described how they had considered a small number of staff returning to the workplace in September 2020. They sent us evidence of a staff survey (specific for UK staff) that was to find out how they felt about coming back. Staff were given a number of options. Staff who were not comfortable returning would continue to be supported to work from home. Those who were happy to come back were allotted time within a rota. They were also issued with PPE and their return to work pack. All staff received training to help them become familiar with changes at the office, including physical distancing, clear signage for one-way systems, cleaning and daily reporting requirements.

Safety and Security of Patient Information

Care and treatment records were complete, accurate, and securely kept. We spoke with staff who had overall responsibility for information governance, who described the measures in place to retain data securely and safely. This included a daily assessment of threats and risks on a global basis. All staff received information governance training.

Systems were in place to ensure that all patient information was stored and kept confidential.

There were policies and IT systems in place to protect the storage and use of all patient information. The service could provide a clear audit trail of who had access to records and from where and when. The service was registered with the Information Commissioner’s Office. There were business contingency plans in place to minimise the risk of losing patient data.

Seeking and acting on feedback from patients and staff

  • Patients could rate the service they received. This was constantly monitored and if it fell below the provider’s standards, this would trigger a review of the consultation to address any shortfalls.
  • Patients were emailed at the end of each consultation with a link to a survey they could complete. The provider actively encouraged patients to respond to this survey and they logged all responses.
  • We saw the results of the most recent feedback data from patients. This showed 95% of patients would recommend the service and 93% were satisfied or very satisfied with the service (592 returned surveys).

GPs working for the service 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.

Staff were supported and encouraged to raise concerns. 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. Staff were also signposted to external organisations if their concerns could not be raised internally. Staff we spoke with felt there was a no blame culture. They were aware of the policy and felt confident they could raise concerns.

We saw the service had conducted a staff survey to ensure the views of staff were heard and acted upon. The provider sent us evidence of a recent survey that was sent to all permanent staff, however it was not possible to limit the results to UK based employees only. The provider told us the survey was not sent to GPs who worked for the service, but they hoped to include them in the future. The staff we spoke with told us they felt their views and feedback was listened to and acted on.

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. Meetings were held either in person or remotely through online meeting facilities. In addition to this, we saw and were told that the communication platform in use by the service was effectively used to encourage learning or to obtain support. For example, GPs used a channel to get real-time clinical advice on consultations or for peer learning. We saw evidence of case discussions where GPs and clinical leads had been involved in the discussion. They also had a channel that was used as a live notice board, where they shared interesting articles or new guidance. In terms of shift communication, they used the platform to hand over cases or to let each other know if there had been any particular issues.

Staff told us they felt encouraged to raise concerns and discuss areas of improvement. There was ongoing discussions at all times about service provision.