Archived: Bramcote Surgery

Updated 16 March 2017

Bramcote Surgery provides primary medical services to approximately 3100 patients through a general medical services contract (GMS). This is a locally agreed contract with NHS England.

The practice was formed over 60 years ago and it is located in purpose built premises in the Bramcote area of Nottingham, about five miles from the city centre. Facilities are on two floors and these include consulting and treatment rooms.

The level of deprivation within the practice population is below the national average with the practice falling into the least deprived decile. The level of deprivation affecting children and older people is below the national average. The practice has a slightly higher than average numbers of patients over 65 years old. Numbers of young people are in line with local and national averages. The practice population is mainly of White British ethnicity.

The clinical team includes two GP partners, a salaried GP (two female, one male), a nurse practitioner, a practice nurse and two healthcare assistants. The clinical team is supported by a practice manager and seven reception and administrative staff. The two healthcare assistants have dual roles including reception roles. It is a teaching practice offering placements for university medical students in their first, second, fourth and fifth year.

The surgery is open from 8am to 6.30pm on Monday to Friday. There are morning and afternoon consulting clinics, with appointments starting at 8.30am up to 5.30pm on Monday, Tuesday, Wednesday and Friday, and up to 6pm on Thursday.

The practice has opted out of providing out-of-hours services to its own patients. This service is provided by Nottingham Emergency Medical Services (NEMS) and is accessed via 111.

Updated 16 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bramcote Surgery on 8 November 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 within the practice. Effective systems were in place to report, record and learn from significant events. Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• Training was provided for staff which equipped them with the skills, knowledge and experience to deliver effective care and treatment.

• Outcomes for people who use services were consistently better than expected when compared to other similar services. Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were mostly above average compared to the national average.

• Feedback from patients about their care was consistently positive and above local and national averages. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Patients told us they were able to get an appointment with a GP when they needed one, with urgent appointments available on the same day.

• The practice was responsive to the needs of their local population, and not just their registered patients. This enabled services to be delivered closer to patient’s homes. For example, a GP provided a vasectomy service and long acting reversible contraception (LARC) services for all patients within their CCG and outside of their CCG. Access to a community ultrasound clinic and consultant gynaecologist clinic hosted by the practice were available to people outside of the practice.

• Improvements were made to the quality of care as a result of complaints and concerns and learning from complaints was shared with staff and stakeholders.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw a number of areas of outstanding practice including:

• There was evidence of a highly engaged patient participation group (PPG) who actively participated in a number of initiatives to enrich the lives of patients. They engaged with the local council and voluntary support groups to support the health and wellbeing of elderly patients.

• The practice was committed to supporting patients identified as having caring responsibilities. A carers drop-in clinic was offered every three months at the practice in cooperation with local carers organisations and provided support, guidance and advice for patients who were responsible for others. This included specialist support for young people who were carers.

• The practice demonstrated high levels of access compared to other practices in the local area. 98% of patients said they found it easy to get through to the surgery by phone, which was consistent with CCG data which showed that telephone calls were answered within 25 seconds.

• Patients were involved in decisions about their care and sought to keep patients informed about self-care. The practice developed in-house checklists to assist with clinical assessments, which were completed by patients prior to appointments. The checklists had been shared with local practices including a practice outside of their CCG, and implemented as examples of good practice.

• Staff, teams and services were committed to working collaboratively. People who have complex needs were supported to receive coordinated care and there are innovative and efficient ways to deliver more joined-up care to people who use services. The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care. Staff were motivated to use their initiative to take on roles such as the carers champion to benefit people using the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 16 March 2017

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

• Clinical staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed.

• The practice nurse provided home visits every Tuesday morning to housebound patients for routine medical care including checks required for long term conditions management.

• A recall process was in place for patients who received anticoagulation treatment to ensure they attended follow-up appointments and their medicines were managed appropriately.

• Regular multidisciplinary meetings were hosted by the practice. For patients with the most complex needs, practice staff worked with relevant health and care professionals to deliver a multidisciplinary package of care. For example, a diabetes specialist nurse held monthly clinics for patients with complex diabetes, enabling them to access care in the community rather than at hospital.

• CCG benchmarking data showed consistently low numbers of unplanned hospital admissions for people with conditions such as chronic obstructive pulmonary disease (COPD), asthma and diabetes. The practice attributed their performance to their recall system and involvement of specialist nursing services for case management.

• People with long term conditions were encouraged to attend structured education courses, for example, diabetes and pulmonary rehabilitation courses, to improve their outcomes. Patients with asthma were given a self-management plan at their annual reviews and provided with a peak flow meter to use at home to monitor their condition.

• The outcomes for patients with long term conditions were mostly above national averages. The overall performance on diabetes related indicators was 99%, compared to the CCG average of 95% and the national average of 90%. The proportion of patients with diabetes who had a flu vaccination in the preceding 12 months was 99%, compared to the CCG average of 96% and the national average of 95%. The exception reporting rate for this indicator was 9%, below the CCG average of 16% and the national average of 20%.

Updated 16 March 2017

The practice is rated as good 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. The practice had a child safeguarding lead nurse and lead GP, and staff were aware of who they were. Meetings were held every six weeks with a health visitor, midwife and school nurse present to review children at risk.

• We found effective monitoring arrangements in place for children who may be at risk. If a patient did not attend a booked appointment on three consecutive occasions, the practice manager contacted them to facilitate a suitable appointment, ensuring that their needs could be reviewed by a GP.

• The practice offered a range of contraception services including implants, coil fittings and a vasectomy service to their patients and those registered with other practices. Vasectomy clinics were held at least once a week with referrals received from practices within and outside the CCG, creating easier access for local people. There were 165 procedures carried in 2016. There were high levels of positive feedback from patients who had received the service.

• Additionally, a consultant gynaecologist held a monthly clinic at the practice, reducing the need for patients to be referred to the hospital to access specialist services.

• The practice developed an in-house checklist to be completed and signed by parents prior to nasal flu vaccinations of their children. The checklist enquired about medicines, allergies and explained the side effects of the vaccination. Staff told us the checklist had been shared with local practices including a practice outside of their CCG as an example of good practice.

• Immunisation rates were high for all standard childhood immunisations. For example, immunisation rates for children under two years old ranged from 97% to 100%, compared to the CCG average of 91% to 98%. Immunisation clinics were arranged around school holidays to encourage attendance at convenient times.

• Benchmarking data showed they had the highest uptake in CCG for all flu vaccinations including patients in this population group. For example, data from 2015/16 showed 63% of all pregnant women were given flu vaccinations, compared to the CCG average of 42%.

• Urgent appointments were available on a daily basis to accommodate children who were unwell.

Updated 16 March 2017

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

• They offered proactive, personalised care to meet the needs of the older people in their population. Weekly multidisciplinary meetings were held to review frail patients and those at risk of hospital admission to plan and deliver care appropriate to their needs. These included all patients living in care homes and those over 90 years old.

• The practice demonstrated a caring approach by supporting their PPG to obtain funding from the local council aimed at enriching the lives of frail and elderly residents in care and nursing homes in their community. The PPG worked with a transport provider to carry elderly patients resident in care homes to school musical productions, and brought school children and teachers to sing Christmas Carols to housebound people in the local care homes.

• The practice was responsive to the needs of older people, and offered GP and nurse home visits and urgent appointments for those with enhanced needs. The practice PPG had invited 274 patients aged 70-80 years old to participate in a health and wellbeing campaign conducted by Age UK. The practice achieved a response rate of 30% and some were assisted in applying for benefit payments which amounted to a total annual gain of approximately £26,000 for patients.

• Feedback from a care home whose residents were registered with the practice was positive about the care and treatment provided, including involvement of the residents’ relatives where appropriate.

• The practice wrote to patients soon after their 65th birthday to invite them for pneumococcal and seasonal flu vaccinations.

• Data from 2015/16 showed 82% of eligible patients aged over 65 years were given flu vaccinations, compared to the CCG average of 74%. Benchmarking data showed they had the highest uptake in the CCG area for flu vaccinations.

• Pneumonia and shingles vaccinations were offered to eligible patients. Vaccination rates for shingles vaccinations offered to patients over 70 years old were consistently above CCG and national averages.

• The practice had developed an in-house checklist to be completed and signed by patients when they attended for shingles vaccinations which enquired about their health and explained the side effects of the vaccination. Staff told us the checklist encouraged patients to have more ownership of their health information and patients experienced shorter appointments as a result of the completing the forms before attending their appointments.

• All patients aged over 75 years old had a named GP for continuity of care.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis and heart failure were in line with or above local and national averages. The proportion of patients with rheumatoid arthritis who had a face-to-face annual review in the preceding 12 months was 100%. This was achieved with an exception reporting rate of 6%, the same as the CCG average of 6% and below the national average of 8%.

Updated 16 March 2017

The practice is rated as good 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 via its website and used social media, such as Twitter, to make available a full range of health promotion and screening information relevant to this group of patients.

• There were a range of services available online. These included arranging and cancelling appointments, requesting repeat prescriptions and accessing medical records.

• Phlebotomy clinics and appointments with the health care assistant were offered from 8.15 am, four times per week.

• Urgent GP appointments were offered from 8am and telephone advice was offered if appropriate. The practice used a text reminder service to patients who had pre-booked appointments sent 24 -48 hours before the appointment.

• Flu clinics were held on Saturdays to accommodate working patients, with ‘sit and wait’ appointments available.

• The practice encouraged all patients aged under 25 years old to have regular sexual health screening, with referrals offered for complex cases to specialist services.

• Travel vaccines were provided by a nurse who had additional qualifications relating to travel.

• Uptake rates for screening were similar or better than the national average. For example, the uptake rate for cervical cancer screening in 2015/16 was 82%, which was in line with the CCG average of 84% and above the national average of 81%.

Updated 16 March 2017

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

• Data showed 81% of the practice’s patients with schizophrenia or other psychoses were on lithium therapy, compared to the CCG average of 79%.

• Performance for mental health related indicators was 98%, compared to the CCG average of 98% and the national average of 93%. The proportion of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding 4 months was 88%, compared to the CCG average of 87% and national average of 90%. There were no patients excepted for this indicator, compared to the CCG average of 2% and the national average of 10%. Additionally, medical students attached to the practice had carried out an audit of reviews carried out on patients with severe mental health conditions, and identified the need to combine information from specialist services with GP notes. GPs told us this had resulted in improved coordinated care for the patients.

• The number of patients with a diagnosis of dementia who had their care reviewed in a face-to-face review in the last 12 months was 74% which was 11% below the local average and 10% below the national average. This was achieved with an exception reporting rate of 10%, which was 5% above the CCG average and 4% above the national average. The practice told us they had employed a salaried GP whose role allowed extra time to be given to regular ward rounds at the nursing home where dementia annual reviews were carried out. Practice supplied data following our inspection showed the practice had achieved 82.5% reviews by January 2017 with no exception reporting recorded.

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

• Patients experiencing poor mental health were told how to access various support groups and voluntary organisations. Referral rates to psychotherapy services were consistently above monthly targets in from April to December 2015. Staff told us they were one of the top five practices reaching their referral target for 2016/17.

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

Updated 16 March 2017

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. The electronic patient record system flagged patients who were known to be vulnerable or at risk to staff, including those with a learning disability and children on the safeguarding register.

• There were 15 patients identified on the learning disabilities register in 2015/16, and 12 had attended a face to face review appointment. If patients did not attend their learning disability review, the practice contacted them by telephone to ensure it they were rebooked at a suitable time. There was a process in place to refer those who declined reviews to the specialist learning disabilities nurse who could arrange to see them at home. Additionally, all staff had attended learning disabilities awareness training.

• There were longer appointments for patients with a learning disability and for others who required this. There were notices in the waiting room and on the practice website advising patients to notify a receptionist if they felt they required additional support when seeing a clinician. Patients with social phobia were offered appointments at the end of the day when there were less people present in the waiting room.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients, including patients on the palliative care register. There were 59 patients on the unplanned admissions register.

• Domestic violence advocacy clinics were hosted by the practice. In addition, all staff had undertaken training in domestic violence.

• 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.

• The practice had identified 76 patients as carers, including young carers, which was equivalent to 2.5% of the practice list. Of these patients, 78% had been invited to attend flu vaccination appointments.

• There was a nominated carers champion in the practice and a carer’s drop-in clinic was offered from the practice premises to provide support, guidance and advice for patients who were responsible for others. This included specialist support for young people who were carers.

• Information was on display that advised patients printed material and practice documents were available in large print, easy-read format and Braille. British Sign Language interpreters were also available for patients who needed them. Staff told us an interpreter had encouraged their partner to join the practice after observing the practice was accessible to people with hearing difficulties. A hearing loop was available in the practice.