Letter from the Chief Inspector of General Practice

At our previous inspection on 5, 6 March 2018, we found, in addition to providing a service for patients through the provider website, www.e-med.co.uk; the provider was also providing consultations, private healthcare referrals and prescriptions for five external companies; ‘Health Express Healthcare’; ‘Menscare UK Ltd’; ‘PharmacyDirectGB’; ‘Healthwise’; and ‘Uk-med’. On 8 March 2018 the provider was issued an urgent Notice of Decision under Section 31 of the Health and Social Care Act 2008, to impose conditions on their registration as a service provider as we found the provider was not providing a safe, effective, caring, responsive and well led service for patients.

We imposed the following urgent conditions on the registration of E-Med Private Medical Services Ltd:

• The registered provider must not provide online doctor consultations or prescribe any medicine or medicinal product that contains a medicine, for service users for any companies or websites other than www.e-med.co.uk.

• The registered provider must not prescribe to any service user any medicine, or medicinal product that contains a medicine, other than Naltrexone.

We carried out an announced comprehensive inspection at E-Med Private Medical Services Ltd on 1 November 2018 to follow up on breaches of regulations.

This report outlines our findings in relation to the service with the above three urgent conditions imposed:

Are services safe? – we found the service was providing a safe service in accordance with the relevant regulations. Specifically:

• Arrangements were in place to safeguard people, including arrangements to check patient identity.
• People were told about the risks associated with medicines used outside of their licence.
• Suitable numbers of staff were employed and appropriately recruited.
• Risks were assessed and action taken to mitigate any risks identified.

Are services effective? - we found the service was providing an effective service in accordance with the relevant regulations. Specifically:

• Following patient consultations information was appropriately shared with a patient’s own GP, with their consent, in line with GMC guidance.
• Quality improvement activity, including clinical audit, took place.
• Staff received the appropriate training to carry out their role.

Are services caring? – we found the service was providing a caring service in accordance with the relevant regulations. Specifically:

• The provider carried out checks to ensure consultations by the doctor met the expected service standards.
• Patient feedback reflected they were satisfied with the service they had received.
• Patients had access to information about clinicians working at the service.

Are services responsive? - we found the service was providing a responsive service in accordance with the relevant regulations. Specifically:

• Information about how to access the service was clear and the service was available 7 days a week.
• The provider did not discriminate against any client group.
• Information about how to complain was available and complaints were handled appropriately.

Are services well-led? - we found the service was providing a well-led service in accordance with the relevant regulations. Specifically:

• The service had clear leadership and governance structures.
• A range of information was used to monitor and improve the quality and performance of the service.
• Patient information was held securely.

The areas where the provider should make improvements are:

• Increase the health information available to patients about leading healthier lives.
• Review the provision of a male consulting doctor to provide patients with a choice of either a male or female clinician to undertake their consultation.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of E-Med Private Medical Services on 31 January 2017. We found this service was not proving safe, effective and well led services in accordance with the relevant regulations but was providing a caring and responsive service.

Following this inspection the provider was issued with a Notice of Decision to impose conditions on their registration in relation to Regulation 17 Good Governance. The condition imposed was the registered provider must develop effective systems and processes to govern activity.

The full comprehensive report of the 31 January 2017 inspection can be found by selecting the ‘reports’ link for E-Med Private Medical Services Ltd on our website at http://www.cqc.org.uk/location/1-2179748601/reports.

This inspection was an announced focussed inspection carried out on 2 August 2017 looking at the issues previously identified and, to check and confirm that the practice had carried out its plan to meet the legal requirements. We found that the provider had taken appropriate action to meet the requirements of the regulations relating to providing a safe, effective and well led service for the E-Med Private Medical Services Ltd website www.emed.co.uk.

At our inspection on 2 August 2017 it was established that E-Med Private Medical Services Ltd was providing an online doctor service for a number of external companies. As a result of this information the provider was issued with a Section 64 letter on 3 August 2017 requesting a definitive list of all companies that E-Med Private Medical Services Ltd had provided medical advice for in the past, presently and plan to do so in the future.

A second Section 64 letter was issued to the provider on 18 September 2017 requesting information about the roles and responsibilities for carrying out the regulated activities for external companies affiliated with E-Med Private Medical Services Ltd.

The information in this report relates to the operations for the E-Med Private Medical Services Ltd www.emed.co.uk website only.

Professor Steve Field

CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at E-Med Private Medical Services Ltd on 31 January 2017 and found this provider was not providing safe, effective and well led services in accordance with the relevant regulations but was providing a caring and responsive service. As a result of this inspection, the provider was required to take urgent action in relation to breaches identified of Regulation 12 of the Health and Social Care Act 2008: ‘Safe care and treatment’ and was issued a Notice of Decision to impose conditions on their registration as a service provider to develop effective systems and processes to govern activity.

The full comprehensive report of the 31 January 2017 inspection can be found by selecting the ‘reports’ link for E-Med Private Medical Services Ltd on our website at http://www.cqc.org.uk/location/1-2179748601/reports.

An announced focussed inspection was carried out on 2 August 2017 to review the issues previously identified at our inspection on 31 January 2017 and, to check and confirm that the service had carried out its plan to meet the legal requirements. At this stage we found that the provider had taken appropriate action to meet the requirements of the regulations relating to providing a safe, effective and well led service for the provider website; www.emed.co.uk.

The full comprehensive report of the 2 August 2017 inspection can be found by selecting the ‘reports’ link for E-Med Private Medical Services Ltd on our website at http://www.cqc.org.uk/location/1-2179748601/reports.

At our inspection on 2 August 2017 it was further established that the provider was providing an online doctor service for a number of external companies. As a result of this information the provider was issued with a series of letters which requested a definitive list of all companies that the provider had provided medical advice for in the past, presently or planned to do so in the future; further information about the roles and responsibilities for carrying out the regulated activities for these external companies; a list of all of the websites associated with these companies for which the provider were providing medical advice, including undertaking patient consultations and prescribing; and a copy of signed contracts between the provider and these companies.

Following receipt of this information we carried out an announced comprehensive inspection at E-Med Private Medical Services Ltd on 5 and 6 March 2018 to inspect the online doctor service provided by the provider for these external companies in addition to the service provided to patients accessing the provider’s own website; www.e-med.co.uk.

Our findings in relation to the key questions were as follows:

Are services safe? – We found this provider was not providing a safe service in accordance with the relevant regulations.

Specifically:

• Staff were unclear what arrangements were in place for identity checks for the external companies they provided the online doctor service for or how children were safeguarded from accessing these services.

• Prescribing was not always in line with national guidance, and people were not told about the risks associated with all medicines used outside of their licence.
• There were no prescribing audits to monitor the quality of prescribing for patients.
• We were not assured there was an effective system in place for the management and learning from safety incidents and alerts.

Are services effective? - We found this provider was not providing an effective service in accordance with the relevant regulations.

Specifically:

• We were not assured, from both our interviews with the doctors and the review of patient records, that doctors had taken into account relevant nationally recognised guidance, particularly in relation to medicines management for the prescribing of asthma, diabetes and erectile dysfunction medicines.

• Our review of patients’ records found multiple examples of patient consultations where there was no evidence of any further follow up questions asked by the doctor to the patient for exploration of patient symptoms for the safe prescribing of some medicines.

• The service did not monitor patient consultations or carry out consultation and prescribing audits in order to improve patient outcomes.
• There was no system in place to identify the ongoing learning needs of staff.
• Following patient consultations information was not appropriately shared with a patient’s NHS GP in line with GMC guidance.

Are services caring? – We found this provider was not providing a caring service in accordance with the relevant regulations.

Specifically:

• The service did not carry out checks to ensure consultations by doctors met the expected service standards.
• Patients did not have access to information about all the doctors working at the service.

Are services responsive? - We found this provider was not providing a responsive service in accordance with the relevant regulations.

Specifically:

• Although the websites were not an emergency service and unlikely to be a service that a patient would access in case of an emergency; not all of the websites advised patients that if they needed immediate medical assistance, to dial 999 or if appropriate to contact their own GP or NHS 111 service.

• Patients were not able to access brief descriptions of the doctors available on any of the websites with the exception of www.e-med.co.uk which gave brief details about one of the doctors undertaking the consultations.

• Information about how to complain was not always available and there was no evidence of complaints received in the last 12 months to assess if these were handled appropriately. We were not assured the provider had oversight of the governance arrangements for how complaints were managed by the companies they provided the online doctor service for.

• We were not assured staff understood and sought patients’ consent to care and treatment in line with legislation and guidance. Clinicians failed to respond appropriately to scenarios we gave them relating to patients mental capacity to make decisions.

Are services well-led? - We found this provider was not providing a well-led service in accordance with the relevant regulations.

Specifically:

• There was a lack of oversight of the governance arrangements of the external companies for which the provider provided online doctor consultations.

• We found the provider had no assurance regarding who was undertaking the pre-screening clinical function of patient consultations or their professional competence to do so, for three of the external companies for which they provided an online doctor service.
• Our review of patient records found no evidence that the doctors clarified medical history or treatment with the patient’s NHS GP, which put patients at potential risk of harm as it meant that the service was reliant upon patients for entering accurate and truthful information about their medical history.
• There was no quality improvement programme in place to monitor the quality of patient consultations and prescribing and make improvements.

• We were not assured the provider had an adequate system in place to provide employees with appropriate guidance to carry out their roles in a safe and effective manner.
• The Director had a lack of oversight of the governance arrangements of the external companies for which the provider provided online doctor consultations and there was a lack of management and clinical leadership in place for the doctors.
• There was a lack of oversight of how the external companies for which the provider provided online doctor consultations, managed and maintained the safety and security of patient information.

We identified regulations that were not being met and the provider must:

• Ensure that care and treatment of patients is only provided with the consent of the relevant person.

• Ensure care and treatment is provided in a safe way to patients.
• Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the breach of regulations at the end of this report.

Enforcement action

On 8 March 2018 the provider was issued an urgent Notice of Decision under Section 31 of the Health and Social Care Act 2008, to impose conditions on their registration as a service provider.

We imposed the following conditions:

• The registered provider must not provide online doctor consultations or prescribe any medicine or medicinal product that contains a medicine, for service users for any companies or websites other than www.e-med.co.uk

• The registered provider must not prescribe to any service user any medicine, or medicinal product that contains a medicine, other than Naltrexone.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice