Archived: NEMS Platform One

Updated 10 October 2017

NEMS Platform One is the registered name for two GP surgeries in Nottingham City centre. The practice opened in February 2010 with a zero patient list, and currently provides primary care to approximately 10,500 patients. The practice has one patient list, meaning that registered patients can access services at both sites which are:

• NEMS Platform One, Station Street, Nottingham NG2 3AJ. This is the main practice.

• NEMS Platform One, 79a Upper Parliament Street, Nottingham, NG1 6LD. This is the branch practice, located 1.5 miles/ 8 minutes (on foot) from the main surgery.

We visited the main practice as part of our inspection.

NEMS Platform One was initially inspected on 30 June 2015 under the provider’s previous registration; NEMS Healthcare Ltd. The overall rating was outstanding. In 2016 the provider’s legal entity changed from NEMS Healthcare Ltd to NEMS Community Benefit Services Limited, requiring the provider to re-register, which was considered a new registration.

All new registrations are inspected within 12 months to assess if the provider is meeting the legal requirements and to apply a rating. In view of the above changes we carried out this announced comprehensive inspection at NEMS Platform One on 28 July 2017.

The provider, NEMS Community Benefit Services Limited is a 'not-for-profit' company, which re-invests any surplus profit to improve services to patients. It is also registered with CQC to provide:

• The urgent medical care and advice out out-of-hours service for Nottingham City and Nottinghamshire South Clinical Commissioning Groups (CCG). This service operates from the same location as NEMS Platform One Practice.

• The urgent medical care and advice out out-of-hours service for Mansfield and Ashfield CCG, which is located at Kings Mill Hospital

The surgery provides primary care services via an Alternative Provider Medical Services (APMS) contract commissioned by NHS England and Nottingham City CCG. APMS contracts provide the opportunity for locally negotiated contracts to supply enhanced and additional primary medical services. The five year contract was awarded in 2010, and has been extended. The contract is due to change in April 2018.

The practice is commissioned with the aim of engaging with hard to reach groups. The diverse population includes city workers, families, students as well as high numbers of patients who are vulnerable, homeless, seeking asylum, have a substance misuse or mental illness. The practice has a significantly lower percentage of patients aged 65 years and over compared to the local and national averages. 85% of patients are under 50 years of age.

The patient population has a 100 different ethnic groups recorded, of which 5% of the patient list are non-English speaking. The practice has a high transient population including students, asylum seekers, refugees and people from overseas. Approximately 200 new patients register each month and 100 patients de-register. The turnover of patients from April 2016 to March 2017 was very high at 37%, due to the high transient population.

The level of deprivation within the practice population is high.

Following the involvement of a national pilot for out of area registration, the practice elected to continue to register patients who live elsewhere and choose to access GP services in Nottingham. The practice had 602 patients who were registered from out of area.

NEMS Platform One is located in purpose built premises, which are spacious and accessible to patients. The provider owns and maintains the main practice building, whilst the branch surgery is located in a shared building. Both practices are located in Nottingham city centre and have good public transport links.

The provider employs nine salaried GPs (three male and six females). All salaried GPs work part time. This equates to 3.29 full time GPs working in the practice. Regular GP locums are used to increase medical capacity, and three regular locums were working at the practice when we undertook our inspection.

The practice was set up to be a nurse led team. The nursing team includes two advanced nurse practitioners, nine practice nurses including a lead nurse and two mental health nurses, a nurse consultant and three health care assistants (HCA). This equates to 7.1 full time nurses and 2.69 HCAs working in the practice. All of the nursing staff are female except for one male.

The clinical team also includes two pharmacists, which equates to 1.6 full time staff. The clinical team is supported by 19 non-clinical staff across the two sites. This includes practice managers, a team leader, administrative and reception staff.

The practice is a teaching practice for medical and nursing students.

The main practice is open Monday to Friday from 8am to 6.30pm. Extended hours appointments are available on Tuesday morning from 7.30 to 8am, Wednesday and Thursday evenings from 6.30 to 7pm and Saturdays from 9am to 1pm.

The branch practice is open Monday to Friday from 9am to 5pm; on Wednesday the hours are extended to 7pm to provide a substance misuse clinic.

Planned GP and nursing appointments times are available across the two practices at varying times of the day.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to NEMS Community Benefit Services Limited out of hours service via the 111 service.

Updated 10 October 2017

Letter from the Chief Inspector of General Practice

NEMS Platform One was initially inspected on 30 June 2015 under the provider’s previous registration; NEMS Healthcare Ltd. The overall rating was outstanding. In 2016 the provider’s legal entity changed from NEMS Healthcare Ltd to NEMS Community Benefit Services Limited, requiring the provider to re-register, which is considered a new registration.

In view of the above changes we carried out an announced comprehensive inspection at NEMS Platform One on 28 July 2017. Overall the practice is rated as outstanding.

Our key findings across the areas we inspected were as follows:

• The practice was commissioned with the aim of engaging with hard to reach groups. The patient population was very diverse and included a high number of people who were vulnerable or had complex needs. It also had a high transient population.

• The staff team understood their patient population well and offered a wide range of services to meet patients’ needs and enable them to be treated locally. They were extremely responsive in engaging with vulnerable and hard to reach groups, to improve their welfare and reduce health inequalities.

• Feedback from patients about their care and the way staff treated them was consistently positive.

• Comprehensive systems were in place to place to protect patients from abuse and avoidable harm. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Opportunities for learning from incidents were maximised.

• The triage and appointment system was flexible and responsive; the staff team were continually reviewing this to meet patients' needs.
• The practice had undergone considerable changes and adopted alternative ways of working to ensure the services were effective. For example, the management of medicines had been strengthened following the appointment of two clinical pharmacists to the staff team.
• The practice team were forward thinking and part of local pilot schemes to improve outcomes for patients.
• The practice had effective clinical and managerial leadership and governance arrangements, which put patient safety and welfare at the heart of what they did. The culture and leadership promoted the delivery of high-quality, compassionate care.
• The premises were designed to meet the patient population, and were well equipped to treat patients and meet their needs.
• The practice actively sought feedback from staff and patients, which it acted on to improve the services. Information about how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.

We saw several areas of outstanding practice:

• To meet patients’ needs the practice provided several key services that were additional to the provider’s contract and performance requirements. For example, 24% of patients had a mental illness, many of who had complex needs. The practice had developed its own primary care mental health services, which included a lead GP and two nurses, one of which was a prescriber. This offered a broad range of services and enabled patients to be treated locally, and reduced the need for them to attend various other services. It also provided personal support and timely intervention to ensure that patients received appropriate care, reducing referrals to secondary services.  

• The practice registered 350 homeless people; some of whom were reluctant to attend main stream health services. To enable more people to access primary care services, the practice had established a weekly GP drop in clinic at one of the main day centres in Nottingham in partnership with the homeless team. The  clinic had been running since June 2017 and was available to anyone attending the centre. The service was enabling people alternative access to healthcare. On average the GP saw 4 patients a week and provided advice to around 3 people a week. 60% of patients were registered with the practice, 30% registered as a temporary patient and 10% registered permanently. 

• In response to the high numbers of patients who had a substance misuse diagnosis, the GP lead for substance misuse held a weekly shared care clinic at both practices with a specialist drug worker from the central recovery team. The branch clinic was also available to patients from other practices and offered evening appointments to support people who worked. The flexible service enabled people to be treated locally and provided timely access to treatment. It also provided holistic care helping patients towards recovery and reducing harm from substance misuse. One of the practice pharmacist's was being mentored to set up prescription medicine misuse clinics with the support of the GPs, which will offer support to patients at other times of the week.

The provider should make the following improvements:

• Identify further patients who are carers and direct them to support available to enable them to carry out their role.

• Ensure that information available at the practice relating to the translation service and UK health services is accessible to non-English speaking patients in different languages.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups including people with long-term conditions.

• The nurses and GPs had lead roles in the management of long-term conditions (LTC).

• The practice offered regular reviews for all chronic disease conditions to check that patients’ health and medicines needs were being met. The reviews were planned around the persons’ birthday.

• The practice contacted patients with LTC discharged from hospital to ensure they were receiving appropriate follow up care and support.

• The practice adopted a pro-active approach to preventing patients from developing LTC such as diabetes. For example, suitable patients were identified and referred to the National Pre-Diabetes Prevention Programme, which provides advice and support to people identified at high risk of developing the condition.

• The diabetes nurse specialist attended a joint monthly clinic with the practice nurses to review patients with diabetes to initiate insulin, or to review more complex problems.

• The practice referred patients with Type 2 diabetes to JUGGLE, which provides a structured diabetes education service.

• Importance was placed on educating patients to self-manage their long-term conditions. For example, the practice was involved in the Year of Care programme, which puts the patient at the centre of their care and supports them to self-manage their condition.

• Opportunistic shingles, pneumococcal and flu vaccinations were offered at routine reviews.

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups including families, children and young people.

• Appointments and telephone consultations were available outside of school and college hours and all children aged under five were seen on the day where needed.

• The practice had a high number of vulnerable children (280). Comprehensive systems were in place to protect children who were vulnerable, at risk of abuse or living in disadvantaged circumstances from avoidable harm.

• All GPs and nurses were trained to Safeguarding level 3. In response to the high number of vulnerable patients and safeguarding cases, all health care assistants, reception and administrative staff were due to complete level 3 safeguarding training by November 2017.

• The practice had a safeguarding lead GP, an administrator and nurse who worked closely with the local safeguarding teams, and attended internal and multi-agency meetings.

• The practice was a site for piloting ‘MAGPIE’, a new partnership information sharing approach, where there may be safeguarding concerns relating to vulnerable children.

• Immunisation rates were relatively high for all standard childhood vaccinations given the high transient population, number of patients from overseas and cultural issues. An effective system was in place for following up children who did not attend their vaccine.

• The practice worked with midwives, health visitors and school nurses to support this population group. For example, the practice ran a weekly baby clinic alongside the health visitor clinic, which enabled staff to provide immunisations to families attending the clinics.

• The practice phoned the parents of all children who did not attend outpatient appointments to offer support to rebook.

• The practice provided family planning services, including regular coil clinics and contraceptive implants.

• Opportunistic chlamydia screening was offered to patients of relevant age.

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups including older people.

• The practice offered proactive, personalised care to meet the needs of older people.

• Patients were supported to remain active and reduce the risk of falls.

• Home visits including a phlebotomy service was available for people who were unable to attend the practice, to ensure their health needs were met.

• The practice contacted all older patients discharged from hospital to ensure they were receiving appropriate follow up care and support.

• The practice phoned elderly patients who do not attend outpatient appointments and offered support to rebook.

• The practice carried out regular searches to establish if patients had been seen or had contacted the practice recently. If no contact had been made a health care assistant would contact them to check all was well.

• The practice had 64 patients aged over 75 years; 59 patients had been seen and reviewed in the last 12 months.

• Patients were offered opportunistic shingles, pneumococcal and flu vaccinations at routine reviews.

• The practice send birthday cards to patients aged 70 and over, which are also used as a reminder to book any outstanding reviews and vaccinations.

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups including working age people.

• The practice offered extended hours appointments including early morning, evening and Saturday mornings.

• Patients were also offered telephone consultations and were able to book appointments by telephone or on line.

• The practice offered online services to make, amend and cancel appointments and to request repeat medicines. Patients were also encouraged to use a nominated pharmacy to have their prescription sent directly for collection.

• The practice offered access to ‘choose and book’ service for patients referred to secondary services, which provided greater choice and flexibility over when and where their test took place.

• Patients could register who lived outside the practice area; 602 patients were registered from out of area.

• Patients were able to receive travel vaccines available on the NHS as well as those only available privately.

• The practice promoted health screening programmes to help keep patients safe. An effective system was in place to follow up and encourage patients who did not attend screening.

• The practice offered NHS Health Checks to eligible patients, where patients were screened for various conditions including dementia, diabetes and heart disease, together with lifestyle advice.

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups including people experiencing poor mental health.

• Approximately 3,400 patients had a mental health diagnosis, which was over 24% of the practice population. The practice held a mental health register.

• Many of the patients had complex health needs and had been discharged by secondary care or were reluctant to engage with other services, requiring regular, on-going support by the practice.

• The practice had developed its own primary care mental health services, which included a lead GP and two mental health nurses. This offered patients a broad range of services, and enabled them to be treated locally.

• The practice sent phone reminders (additional to text) for patients with appointments to encourage them to attend.

• The practice contacted all patients discharged from hospital to ensure they were receiving appropriate follow up care and support.

• The practice participated in Physform scheme, which focuses on the physical health of patients on their mental health register.

• The practice had an unusually low incidence of patients with dementia (six in total) due to the practice demographics.

• The practice screened patients for dementia as part of the new patient check and at annual reviews, to facilitate early referral and diagnosis where dementia was indicated.

• The staff team worked in partnership with other services, to ensure that patients’ needs were regularly reviewed, and that appropriate risk assessments and care plans were in place.

Updated 10 October 2017

The practice is rated as outstanding for responsive and well led across all population groups, including people whose circumstances may make them vulnerable.

• The practice had high numbers of patients who were vulnerable and held a register of patients.

• Longer appointments were available for patients who needed them.

• Patients with no address could register with the practice and receive mail on their behalf. The practice registered 350 homeless people, which was 40% of Nottingham’s homeless health team’s service users.

• In response to the need for a GP outreach clinic, the practice had established a weekly GP drop in clinic at the main homeless day centre in partnership with Nottingham’s homeless team.

• The practice had a vulnerable adult lead nurse and GP who co-ordinated patients care, and worked with other services including the homeless team, refugee forum, probation hostels and drug and alcohol team. They also attended monthly multi-agency (MDT) protection meetings.

• Over 8% of the patient list (800 plus patients) had a substance misuse diagnosis. The GP lead for substance misuse held a weekly shared care clinic at both practices with a specialist drug worker from the central recovery team. This enabled patients to be treated locally.

• Information was available for vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in children and adults whose circumstances may make them vulnerable. They were aware of their responsibilities to share information, record safeguarding concerns and knew how to contact relevant agencies.