168 Medical Group

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The practice had implemented multidisciplinary work to address the needs of the local population. Staff identified areas of unmet need and established care pathways that went beyond treatment needs to include social prescribing and health promotion interventions. There was a particular focus on supporting patients with needs relating to mental health, sexual health, and substance dependency.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff worked closely with patients to understand and assess their needs. They persevered where patients could not clearly articulate their symptoms or concerns and worked with the wider multidisciplinary team to explore the most effective treatment options. Feedback from patients was consistently positive and people commented on the efforts of staff to understand their conditions and find the most appropriate specialist care for them.

Staff spoke positively of training and processes available to support them in assessing patient’s needs. They said the senior team supported them to develop partnerships and care pathways with colleagues in the community and in non-profit organisations. This approach helped them coordinate complex care with specialists in sexual health, drug use reduction, and mental health support. For example, the team adopted Faculty of Sexual and Reproductive Health national guidance on providing care for women living with cardiomyopathy who wished to get pregnant. This reflected a good understanding of the needs of local people, which included a relatively high rate of the condition. Staff identified opportunities for such work during clinical and team meetings and as part of learning from incidents. Staff had an understanding of the health inequalities and community challenges in the local area. The specialist mental health nurse worked within a shared care system to provide support for patients with drug and alcohol addiction and mental health conditions. The mental health nurse commenced care plans with patients after a GP had assessed them. The team extended this service to care homes and it formed part of the practice’s comprehensive approach to care for people living in social care facilities. Staff continuously sought opportunities to establish health promotion interventional services. The practice commissioned a 12-week programme to reverse or improve the impact of type 2 diabetes through the primary care network health collaborative. The team also established a prescribing nurse-led hormone replacement therapy service in the practice to provide more comprehensive long-term care.

The service had a comprehensive system to make sure care and treatment was provided in line with the most recent up to date guidance. Staff benchmarked care against National Institute for Health and Care Excellence (NICE) standards and used a digital resource at Integrated Care Board (ICB) level to ensure care pathways and decisions were consistent. The practice maintained a detailed, up-to-date understanding of the demographics and needs of the local population. They established partnerships with external agencies to plan and deliver interventions and support services. This included a pain referral service to provide long-term effective management that avoided opiates. Other specialist pathways and multidisciplinary working included patients with eating disorders and risks relating to suicide and self-harm commissioned by the practice. The practice had developed in-house specialist nurse-led services for sexual health and mental health. Patients could self-refer or be referred by another organisation and the services expanded capacity and care availability in the area. These services reduced pressure on the wider health system and provided patients with access to care such as complex gynaecology, cervical screening, and mental health interventions. Complex gynaecology included patients with multiple and long-term needs. A GP with a specialist interest led this service and consultants from the NHS trust provided appropriate supervision arrangements, including clinical sessions in the practice. Staff proactively coordinated health promotion and health checks for patients reflecting the significantly higher rates of pre-diabetes, diabetes type 2, and obesity in the local area. The clinical team were trained to identify insulin resistance and offer lifestyle advice to reduce risk. The practice followed NICE guidance on the primary prevention of ischaemic heart disease and expanded local public health provision by funding community public health lifestyle coaches.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.