The Care Quality Commission (CQC) has downgraded its rating for Doctor Care Anywhere, which provides services for Axa Health’s private medical insurance (PMI) customers, to requires improvement.
The regulator downgraded Doctor Care Anywhere in the areas of being safe and being well-led – raising concerns about how doctors were prescribing medication and about nurses not having the required competences.
It said Doctor Care Anywhere must make improvements to “ensure care and treatment is provided in a safe way to patients” and “establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care”.
The orders follow a routine inspection of the virtual GP provider. Upon its last review in 2019 Doctor Care Anywhere had been rated as good overall by the CQC and good in each of the five categories it assesses.
In its latest report, alongside the areas of patient safety and governance which the CQC said Doctor Care Anywhere must improve, it made several further recommendations that the provider should improve.
It said the provider should also:
- review the mechanisms for disseminating information about incidents in order to be confident that all staff are made aware of any learning from incidents;
- continue to focus on and review staff engagement;
- and review the arrangements for all teams in relation to formal team meetings.
Consequently the CQC rated Doctor Care Anywhere as ‘requires improvement overall’ and in the areas of being safe and being well-led.
It was rated as good for services being effective, being caring and being responsive to people’s needs.
Doctors prescribing outside of rules
The CQC revealed Doctor Care Anywhere required improvement around patient safety after finding doctors prescribing outside their protocols and guidelines and advance nurse practitioners (ANPs) operating without experience in all the areas expected.
Concerns around prescribing focused on the number of staff allocated to auditing daily prescribing, which the CQC said was insufficient for an organisation with more than 400 prescribers.
More than 60,000 consultations were conducted in June 2023 and 20,000 of these resulted in a prescription.
The firm had also not identified that some clinicians had prescribed outside their prescribing protocols and evidence-based guidelines and the reasons for deviating away from these were not sufficiently documented in clinical notes.
Clinicians were able to issue a private prescription to patients and should only prescribe from a set list of medicines which the provider had risk-assessed, however, the CQC found instances where this was not followed.
When the regulator raised concerns during the inspection it said Doctor Care Anywhere immediately amended the computer system and on the final day of inspection clinicians could only prescribe medicines contained in their formulary and this had been immediately communicated to all clinicians.
Nurses lacking full competences
Doctor Care Anywhere had also experienced rapid growth in its provision of advance nurse practitioners, using a recruitment agency for some of this hiring, and while it had a recruitment policy and procedure in place, the CQC noted it was not always followed.
When the CQC reviewed some recruitment files, it found these did not all have the necessary documentation to evidence ANPs had the necessary experience and competence to consult in all the areas expected.
This was not in accordance with the provider’s recruitment policy. It further found the nurses who were recruited externally had not undergone a thorough assessment of their skills and the provider could not confirm they were consulting within their scope of competence.
On raising this during the inspection, the regulator noted Doctor Care Anywhere immediately stopped these nurses carrying out consultations and conducted an immediate internal assessment of those staff.
The provider told the CQC it had identified some ANPs who required additional training and support while undertaking their post-start reviews which had coincided with the inspection. As a result it had decided to disengage them, all of whom had been recruited through the agency.
The provider was also found to not have sufficient oversight of recruitment when they had contracted the agency to recruit the ANPs on its behalf.
And the CQC added it was unable to assess at this inspection whether the changes made would be embedded and sustained as the provider continued to upscale.
Better governance and oversight
On the provider’s rating for being well-led, the CQC revealed it found some staff were not always aware of their own roles and responsibilities and that of other managers.
During CQC discussions with staff there were assumptions that others were doing work with regards to oversight and monitoring and as a result, senior GP leads and pharmacists did not have good oversight of prescribing.
The CQC added governance arrangements in relation to monitoring, auditing and staff resources needed to be reviewed to ensure prescribing protocols were adhered by all clinicians and that consultation notes met General Medical Council (GMC) standards.
However, the provider received a good rating for being effective, being caring and being responsive. Findings in these areas included:
- The service had systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved processes.
- The provider had systems in place to protect people from avoidable harm and abuse
- Staff involved and treated people with compassion, kindness, dignity and respect.
- Patients could access care and treatment from the service within an appropriate timescale for their needs.
Health & Protection approached Doctor Care Anywhere and Axa Health for interviews about the CQC review but no-one was made available from either firm.
Health & Protection also submitted questions to both providers including what changes were being made to address the CQC’s concerns about patient safety, the effect on services, how patients would be impacted, and if Axa Health would continue using Doctor Care Anywhere.
Both providers responded with statements.
Doctor Care Anywhere told Health & Protection it had introduced changes to its policies and procedures to reflect the CQC’s inspection and would continue to engage with it to conclude the inspection process.
Axa Health said changes had been made and added the service was still available to members.
In its statement, Doctor Care Anywhere said: “We welcome CQC inspections as they provide an independent review of the quality of care our patients receive. We were praised in many areas, particularly in how we safeguard adults and children and awarded Good across three domains during the inspection.
“Over the past 12 months, Doctor Care Anywhere has delivered over 700,000 appointments to patients with no occurrences of reportable patient harm. In addition, CQC did not identify any incidences of patient harm attributable to the specific areas they have identified as requiring improvement, relating to recruitment documentation and auditing procedures.
“Since the inspection we have put in place changes to our policies and procedures to reflect the feedback from the inspection and we continue to engage with the CQC to conclude the inspection process.”
In its statement Axa Health said: “Doctor Care Anywhere has put in place changes to its policies and procedures to reflect the feedback from the CQC and is continuing to work with the CQC.
“We want to reassure members who are using the service that it remains available to them.
“We welcome CQC inspections for all our providers to ensure an independent view of the quality of care our members receive.”
Other virtual GP providers
Four other major virtual GP providers offer services to private medical insurers in the UK and at their latest review all were rated as good overall.
The CQC has not inspected Babylon since being taken over, but its last CQC rating was good in the areas of being safe, effective, caring and responsive and outstanding for being well-led.
Square Health and HealthHero were rated good across the board at their latest inspections while Livi was rated good for being safe, effective and caring and outstanding for being responsive and well-led.