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A report by the Care Quality Commission (CQC) on the quality of online primary care services has highlighted safe prescribing issues, variable information sharing and a lack of communication with patients’ NHS GPs.
The healthcare watchdog inspected 35 online or app-based GP services between November 2016 and July 2017, and later re-inspected 16 of those to see if services had improved.
The services were assessed against five areas looking at whether they are safe, caring, effective, responsive to people’s needs and well-led.
Although the CQC found services had improved in those practices re-inspected, it reported continued concerns over the quality of services in some practices.
During the first set of inspections, a whopping 86% of primary care services were found “not to be providing ‘safe’ care” according to regulations. This improved to 43% in the re-inspections.
One of the key issues regarding safety was inappropriate prescribing, particularly of antibiotics and for patients with long-term conditions.
“There were a number of concerns relating to safe prescribing, which were often exacerbated by a lack of clinical oversight and governance to ensure that clinicians were prescribing appropriately,” the report said.
“There is also concern that some clinicians are managing the challenge presented by the remote nature of care by lowering the threshold at which they prescribe antibiotics.”
This was a particular issue in video-based services where clinicians weren’t able to “effectively carry out the usual clinical assessment that would be normal practice in a face-to-face setting, such as examining a patient’s chest, ears or throat,” which led to the threshold for prescribing being lowered.
Information sharing shortcuts
Other safety concerns included a variation in the level of information sharing between the provider and patients’ regular GPs, as well as awareness of why it’s important to share information to ensure, for instance, safe prescribing of medicines.
While some providers had excellent information sharing practices in place, others were not as rigorous. Many of the providers did ask patients to consent to their information being shared, however, some providers “only collected details of a patient’s GP if the patient gave consent to share the information, and GP details were not required to be recorded irrespective of whether information would be shared”.
Steve Field, CQC
“In these providers, for patients that did not provide consent, there were no details to fall back on in case of an emergency,” the report said.
“Even when patients gave consent to share information, we found examples where information had not been shared with their GP. In one case, a provider had not shared over 400 patient contacts with GPs, when they had the consent to do so and should have done.”
Steve Field, CQC chief inspector of general practice, said innovative care services, such as having online or app-based GP consultations, have huge potential, but must ensure they provide quality care.
“While innovation should be encouraged, it must never come at the expense of quality. As with all healthcare services, patient safety must be at the heart of all decisions around what kind of care is offered and how it is delivered,” he said.
Read more about online health services
- NHS roadmap for digital services sets out plans for launching a joined-up NHS app, piloting its citizen ID platform and moving across to the NHS.uk website.
- NHS England’s GP contract says practices must move to e-referrals by October 2018, and work on improving uptake of patients using online services to 30%.
- The NHS is looking for an organisation to undertake an independent review of the on-demand virtual GP app, allowing patients in London to access GP services using their smartphones.
“This is why we have taken action where we have seen risks to patients – and why we have been encouraged to see many providers take note of our findings and make swift improvements to how they operate,” said Field.
He added that online GP appointments had an important place in the future of health provision, but the service was still in its infancy, and as it continued to evolve, everyone from the CQC to the Department of Health and Social Care and providers themselves should work together to ensure the care is always safe and of high quality.
A question of identity
Safeguarding and identity verification were also issues that came up during the first inspection, with some providers having no system to verify identity, and would only ask for verification of patients if they thought it necessary.
Other providers would issue prescriptions without checking ID, and some even allowed members of a patient’s family to access their services without checking the identity of those family members.
On re-inspection, the CQC found some improvements.
“For example, when re-inspecting a real-time video-based provider, we found stronger identity checks of the children and relatives of corporate customers,” the report said. “We also found that providers had moved from minimal identity checking to using the services of an identity checking agency.”