Leyburn Medical Practice

Updated 7 December 2016

Leyburn Medical Practice is a purpose built GP premises which is based in the market town of Leyburn, Wensleydale. The practice also provides a minor injury unit which is open to registered and non-registered patients. It has a General Medical Services (GMS) contract and is a dispensing practice. The practice is also a teaching and training practice and currently has three GP Registrars and annual medical student placements.

The area covered by the practice is Leyburn and the surrounding villages. This area in the Yorkshire Dales is rural and has a larger proportion of older retired patients than local and national averages. It also provides services for those from the farming community. The average distance to the practice for patients is nearly two miles. The nearest hospitals are 18, 25 or 40 miles away depending on the level of specialist service required. The practice also provides care to patients on holiday in the area. There are plans to develop the area in the next 10-15 years to include social housing. The practice list size is currently 5949. The practice catchment area is classed as 8 out of 10 in the Indices of Multiple Deprivation (The lower the Indices of Multiple Deprivation (IMD) decile the more deprived an area is).

In April 2016 the practice took over the governance of a practice which is situated approximately eight miles away. The aim of the practice is to facilitate cross site working, and they have already implemented shared policies and procedures with staff who have access to information technology at both sites.

Car parking facilities are available but transport links are poor for the surrounding villages.

The practice consists of five GP partners (three female and two male). Some of the GPs also work at the other practice. There are two nurse practitioners, four practice nurses and three health care assistants, all of which are female. They have two managing partners and a range of dispensing, reception and administration staff.

The practice is open Monday to Friday from 8am to 6.30pm and offers extended hours on Tuesdays and Thursdays from 6.30pm to 7.15pm. From 6.30pm to 8am the service is covered by the out of hours service. The out of hours is accessed through the 111 service and is provided by Harrogate District Hospital Foundation Trust. Appointments are available from 8.30am and are available on the day and can be booked up to eight weeks in advance. The minor injuries unit is open from 8.30am to 6.30pm Monday to Friday and is supported by the GPs when the paramedic is not available.

Updated 7 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Leyburn Medical Practice on 4 October 2016. Overall the practice is rated as outstanding.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• The practice had recognised the challenges that they faced with regard to the rurality of the practice and had provided services closer to home.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Diabetes management was highly regarded by the practice and there were high levels of symptom control and low levels of hospital admissions. The practice participated in insulin initiation.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs. There was a minor injuries service supported by a community Paramedic Practitioner as the nearest accident and emergency service was 18 miles away.

• The practice provided a dermatology service. They had invested in a dermoscope and one of the GPs had undertaken extra training.

• There was a clear leadership structure and staff felt supported by the management team. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice:

The leadership in the practice drove continuous improvement and staff were motivated and accountable for delivering change. Safe innovation and learning was celebrated. There was a clear proactive approach to seeking out and embedding new ways of providing care and treatment. The practice had introduced a bonus scheme to incentivise and reward staff and recognise effective care.

The practice demonstrated innovative improvement and practice within a rural area which they shared this with other organisations. The practice had a Paramedic Practitioner; we were told that this was the first example of this service in the country due to the locality of the practice.

The practice had taken over the governance of another local practice that needed support and were transferring learning and leadership skills.

The practice had worked closely with the district nursing team and hospital to develop a leg ulcer protocol and with the hospital to develop a deep vein thrombosis care (DVT) protocol. These had been adopted in the local area and provided this care closer to home with a smooth and patient centred process. The practice also provided an ultrasound service and a vasectomy service. This was economically beneficial to the local health economy as well as offering a convenient service to patients from the local community.

The practice had devised and implemented pre-appointment questionnaires that were sent out to patients suffering from asthma and coronary heart disease as they had recognised that there was a high proportion of these patients who did not attend for reviews. This system allowed the practice to reach out to these patients, be updated on their condition and to detect and call in those who needed additional treatment. They were able to demonstrate a year on year increase in asthma reviews.

The areas where the provider should make improve are:

Ensure that systems are in place to monitor prescriptions through the practice in line with national guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 December 2016

The practice is rated as outstanding for the care of people with long-term conditions.

• The practice had a large proportion of patients with long term conditions at 60%.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. The nursing team had devised a questionnaire for patients with coronary heart disease (CHD) and asthma; this helped ensure that only those needing care were seen but that records were updated accordingly.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. Patients with co-morbidities had all of their conditions reviewed at the clinic related to their main condition.

• The practice offered insulin initiation for its diabetic patients and had low admission rates for these patients.

• The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) was 5 mmol/l or less (01/04/2014 to 31/03/2015) was 88% which was above local figures of 83% and national figures of 81%.

• The percentage of patients with diabetes, on the register, in whom the last HbA1c was 64 mmol/mol or less in the preceding 12 months (01/04/2014 to 31/03/2015) was 84% which was above local figures of 80% and national figures of 78%.

• Longer appointments and home visits were available when needed.

Updated 7 December 2016

The practice is rated as outstanding for the care of families, children and young people.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The percentage of women aged 25-64 whose notes recorded that a cervical screening test had been performed in the preceding 5 years (01/04/2014 to 31/03/2015) was 81% which was in line with local figures of 84% and national figures of 82%.

• The practice provided a minor injuries and ultrasound service as the nearest hospital was 18 miles away.

• The practice provided a no scalpel vasectomy service which had been commissioned by the local CCG.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 7 December 2016

The practice is rated as outstanding for the care of older people.

• There was a higher than local and national average number of patients in the older age group and the demand for home visits was high. The percentage of patients aged 65 plus years was 30% compared to the local average of 24% and the national average of 17%.
• The practice offered proactive, personalised care to meet the needs of the older people in its population.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• There was a paramedic practitioner as the nearest accident and emergency service was 18 miles away.

• The practice offered a free home delivery service for its dispensing patients.

• The practice offered an evidence based leg ulcer clinic to provide care closer to home.

Updated 7 December 2016

The practice is rated as outstanding for the care of working-age people (including those recently retired and students).

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• They had devised a deep vein thrombosis protocol that provided a smooth and patient-centred process closer to home.

• The practice had invested in a dermoscope and extra training and provided a dermatology service for care closer to home.

Updated 7 December 2016

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia).

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2014 to 31/03/2015) was 94% which was comparable to the local average of 93% and above the national average of 88%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

• The practice had told patients experiencing poor mental health how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 7 December 2016

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.