Drs. Howe and Hendriksz Also known as Lostwithiel Medical Practice

Updated 5 April 2018

Lostwithiel Medical Practice is situated in the semi-rural town of Lostwithiel in Cornwall. The practice provides primary medical services to people living in Lostwithiel and the surrounding areas. The practice provides services to a local population, the vast majority of whom are Cornish.

The deprivation decile rating for this area is six (with one being the most deprived and 10 being the least deprived). The 2011 census data shows that the majority of the local population identify themselves as being White British.

The practice provides a primary medical service to approximately 4,958 patients of a diverse age group. The practice has a team of two male GP partners, together with one female salaried GP and a female GP registrar. The whole time equivalent is two and one third. In addition there is a practice manager, and additional administrative and reception staff. The GP team were supported by a data quality manager, three dispensary staff, three practice nurses (two of which were prescribing nurses), a health care assistant and additional administration staff.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, visiting consultant outpatient services, the local acute care at home team, an early intervention team and a community matron. Other health care professionals visited the practice on a regular basis.

The practice is open from 8am to 6.30pm Monday to Friday and takes all telephone calls during this time; it does not close at lunchtimes. Appointments are available throughout the working day. Extended hours are provided on Tuesdays and Thursdays from 6.30pm until 8pm. In addition, and in response to winter pressures, GPs had started offering targeted appointments on a Saturday morning from 9am until 12pm, to support patients with identified clinical needs and to support both the local nursing homes, elderly frail still at home and any patient seen recently for whom there is concern that might necessitate urgent admission.

Outside opening times, and including from 6.30pm to 8.00pm, patients are directed to contact the out-of-hour’s service and the NHS 111 number; this is in line with local contract arrangements.

The practice offers a range of appointment types including face to face same day appointments, telephone consultations and advance appointments (four to five weeks in advance) as well as online services such as repeat prescriptions.

The practice has a Personal Medical Services (PMS) contract with NHS England.

This report relates to the regulatory activities being carried out at the following location

Lostwithiel Medical Practice

North Street

Lostwithiel

Cornwall

PL22 0EF

We visited this location during our inspection.

Updated 5 April 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Outstanding overall. (Previous inspection January 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Outstanding

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? - Outstanding

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Outstanding

People with long-term conditions – Outstanding

Families, children and young people – Outstanding

Working age people (including those recently retired and students – Outstanding

People whose circumstances may make them vulnerable – Outstanding

People experiencing poor mental health (including people with dementia) - Outstanding

We carried out an announced comprehensive inspection at Lostwithiel Medical Practice on 23 January 2018 as part of our planned inspection programme.

At this inspection we found:

• The practice had proven its safeguarding processes were effective and had been commended by the local authority on its use of these processes.
• Outcomes for patients who used services were consistently better than expected when compared with other similar services.
• We saw examples of where practice GPs had provided compassionate care following unexpected bereavements or when a simple act of kindness made a difference. For example, one GP took the elderly husband of a patient fishing at a weekend having arranged care for the patient’s wife. GPs considered patient’s emotional and social needs as important as their physical needs.
• All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and accreditation were proactively pursued. High performance was recognised by credible external bodies.
• A systematic approach was taken in working to improve care outcomes, tackle health inequalities and obtain best value for money. The practice performed better for antibiotic prescribing compared to the 11 other practices in the mid Cornwall locality, which meant reduced costs for the NHS and reduced risks of antibiotic resistance to patients.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it, in a way and at a time that suited them.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice had a very low emergency admission to hospital rate compared to other practices in the locality. The practice unplanned admission to hospital rate (mid Cornwall locality) was the best rate in the locality of 12 practices. Lostwithiel Med Practice was 26% better than the locality rate and 25% better than the average rate for Cornwall.

• The practice had very low accident and emergency (A&E) attendances, having achieved the second lowest of 12 practices in the locality. NHSE IRIS reporting data showed that in 2016-17 period 1,245 practice patients had attended A&E, and in the 2017-18 period 1,264 attended, which was the second lowest rise in the locality. The practice was 31% lower than the locality and 33% lower than Cornwall averages. The practice told us they were proactive in attending to patients with minor injuries at the practice, in order to achieve this low rate.

We found several examples of outstanding practice. These included:

• The practice employed two specialist consultant orthopaedic surgeons. The practice had developed this service due to the particular difficulties these patient groups had in travelling long distances from this rural area to hospital-based services. The practice also provided secretarial services which ensured patient records were updated in a timely and accurate manner. Kernow CCG paid the practice for providing the service and the practice paid and employed the consultants directly, thereby saving the NHS money. The practice was in the process of extending this successful service to include a rheumatologist, a psychiatrist and ENT (Ear, nose and throat) specialists. Data provided demonstrated an extremely low DNA (did not attend) rate and a very positive patient experience.  
• Three key areas of outstanding practice included dementia research, having a cancer champion nurse and an elder care co-ordinator nurse. Practice dementia research had been endorsed by the National Clinical Director for dementia in England. The practice developed specialist dementia nurse services who had provided care as a fully-integrated service by the practice to both the patient and the carers. They had provided home visits and ensured continuity of care for those diagnosed with dementia or mild cognitive impairment. A cancer champion nurse raised awareness across the clinical team in order for cancer to be taken into account when patients attended for other reasons. An elder care co-ordinator nurse specifically supported local care homes. This increased the amount of time practice GPs spent providing a holistic approach to a significant patient population with complex needs. Positive outcomes for patients included reductions in referral rates, low emergency admission rates and patients with deaths at home rather than in hospital, a low referral to consultant rates, thorough care planning and more accurate diagnosis, and increased awareness of the difficulties vulnerable groups of patients faced on a daily basis.
• The practice had gained SAVVY level two, (a county-wide initiative by the council supporting improved access to GP services for young people) approval. This indicated a focus on the emotional health and well-being of young people. Staff encouraged young people to visit the practice and engage with their GP and reassure them that their appointments were entirely confidential. The practice used their SAVVY level two accreditation to maintain the full confidence of its young patients. This was not only about teenage pregnancy rates(total terminations since April 2017 to date numbered three) but about sexual health (participating in chlamydia screening was part of SAVVY level two requirements), providing free condoms, encouraginghealthy living, staying well andbeing safe.Extended opening times with pre-bookable appointments ensured that the target age range of 13 to 19 years could find the practice accessible at all times). The differing levels for SAVVY recognition was an assessment of approachability, accessibility, a variety of services provided in-house, publicising services for young people and included an inspection visit.
• GPs and nurses had created and regularly updated patient information leaflets (PILS) and public health leaflets (PHILS) which were available on a shared computer drive throughout the building for access by all staff and clinicians. These covered a variety of topics and were given to patients as an adjunct to consultations and explanations for specific medical conditions. The leaflets were based on National Institute for Health and Care Excellence (NICE) guidance and examples include spirometry, blood tests and vaccinations. There was also a handout available giving links to health information sites. Additional information and links were provided on the practice website.