On 23 March 2018, the Care Quality Commission (CQC) published a report entitled ‘The state of care in independent online primary health services’. It set out the findings from the CQC’s programme of inspections of primary healthcare service providers who provide services online.
Using one of the online providers, patients can request a doctor to prescribe medicines from a range of options. Normally, a patient is asked to select their symptoms or diagnosis from a drop down menu and is then invited to choose the drug. The prescription is then reviewed by a clinician and passed to a pharmacy to deliver the prescribed medicine.
Since November 2016, the CQC has inspected every company in England that provides online primary care services. Each provider had five key areas assessed, namely whether they are safe, caring, effective, responsive to people’s needs and well-led.
Significant concerns found
On 3 March 2017, in open correspondence to providers of online primary care, the CQC stated:
‘CQC’s inspections of some companies that provide online primary care have found significant concerns about patient safety. […]
Although CQC acknowledges that well-run services can offer a convenient and effective form of treatment, inspectors have found services that were too quick to sell medicines without doing enough to check whether they were appropriate, meaning that patients could be at risk of harm.’
In its report, the CQC found that although there were many positives, there were still a number of key issues. Six common themes of poor care were identified:
- Safe prescribing
This was often exacerbated by a lack of clinical oversight and governance to ensure that clinicians prescribed appropriately. There were also concerns that some clinicians lowered the threshold by which they prescribed antibiotics due to challenges created by the remote nature of care.
- Safeguarding in the context of an online environment
The CQC found that providers did not always have appropriate and clear safeguarding systems to avoid abuse. There was also insufficient understanding of safeguarding, with some clinicians failing to respond appropriately to scenarios relating to potential safeguarding issues.
- Verifying patient identity to provide safe care and treatment
The CQC stated that it is aware that there is lack of clear guidance for online providers in respect of identity checking and that it is difficult to eliminate risk entirely. Nevertheless, even where systems and procedures were implemented to verify identity, these were often inadequate or not followed.
- Assessing mental capacity
In its report, the CQC emphasised the importance of a robust process to identify any concerns relating to lack of mental capacity. Some providers, however, had no procedures in place or these were inadequate. Examples of this included some providers assuming that adults had capacity if they were able to register and complete a prescription or if they agreed to the terms of conditions of the website.
- Obtaining consent
The CQC identified that some clinicians did not understand the need for consent or had policies which were not up-to-date. Inspections also identified a lack of understanding of the Mental Capacity Act 2005, which meant that some clinicians did not ask their patients’ consent for care and treatment.
- Communicating with patients’ GPs
The investigators found examples of some services not sharing information with their patients’ GPs. The CQC stated that ‘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.’
The future for online primary care
These issues show that providing primary care online is a challenging task. The CQC, however, stated that following re-inspections of 16 online primary care providers, 14 have demonstrated improvement against some of the key areas. There is still much work that needs to be done, but there are some important considerations that need to be borne in mind by both clinicians and providers.
Delivering primary care online is a rapidly evolving field of practice. The ability to access primary care by way of a computer or a smartphone provides many new possibilities both for the patients and the providers. The risks of delivering such care, on the other hand, are higher than delivering it face to face.
Clinicians must act responsibly and balance the effects of accessibility and new business opportunities with a risk of providing unsafe treatment to patients. They need to take account of the guidance of their regulators, such as General Medical Council and their defence organisations.
See also our related briefing: Primary care online – A revolution in modern society or a professional minefield?