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CQC outstanding practice: Is your practice effective?

Key learning points for GP practices from the CQC's examples of outstanding practice.

Caring for hard to reach groups

Case study 1: The Park Medical Practice in Derby ran a health and wellbeing campaign which encouraged men to see a GP or nurse about any health issues, or lifestyle changes. This resulted in an additional 286 men attending the practice between June to August 2014 compared to the same period for the previous year.

Case study 2: One of the GPs at West Road Medical Centre in Newcastle worked with a local charity to ensure that information about preventing and managing diabetes was available to patients in ethnic minority communities. The practice also identified a specific group of male patients (taxi drivers from south Asian communities) that was hard to reach and worked in partnership with the charity to produce another information leaflet about diabetes, specifically for this group, which was distributed via the Newcastle British Bangladeshi Taxi Union.

Learning points:

  • How does the practice promote screening programmes?  (NHS healthchecks, cancer screening, learning disability health checks)
  • Can you provide examples of how you have been proactive in getting these patients in?
  • How do you monitor your screening programmes?
  • What have you done to increase uptake of these?
  • Can you describe your patient population?  (age, sex, ethnicity, deprivation)
  • Are you aware of local initiatives that are available that target any hard to reach groups?
  • Do you take steps to signpost patients to local resources?
  • Can you give examples from your PPG of good practice and actions that have resulted in improvements for your patient population?

Empowering patients

Case study: Elgar House Surgery in Worcestershire has an Xpert Diabetes Programme (XDP), which is run by their advanced nurse practitioner. This is a six-week structured group-based education programme aiming to give patients the knowledge, skills and confidence necessary to self-manage their diabetes. The national database figures for 2014 showed improved outcomes for patients such as weight loss, reduction in HbA1c (blood sugar levels) and reduced cholesterol. Patients also gave very positive feedback.

Learning points:

  • Are you aware of any patient education programmes being run locally?
  • Do you have the resources to set up your own patient education programme for a specific condition?
  • Have any of your staff undertaken training on motivational interviewing techniques?
  • How do your staff encourage patients to take ownership of their health?
  • How do you support your staff to access training and development?

Providing high quality additional services

Case study: The practice nurses at St Thomas Medical Group in Exeter, Devon had worked with the dermatology department at the local hospital to receive training and advice. This included extended tissue viability training to enable them to provide complex leg ulcer dressings for patients at the practice, which avoided the need to attend the community leg ulcer clinic on the other side of the city.

Learning points:

  • Do you have examples where your practice provides high quality additional services?
  • How do you identify training needs?
  • Can you provide examples of the training schedule for the practice and how this has resulted in improved outcomes for patients?
  • Are there examples of where you have worked collaboratively in order to provide care closer to home?

Forming strong links with the community

Case study 1: Albion Surgery in Liverpool works with other community agencies to deliver ‘social prescribing’. Patients who were suffering from anxiety as a result of financial problems received a prescription for advice from benefits advisers and debt counsellors. The advice sessions identified that some patients had not been receiving their full benefit entitlement, and appropriate action was taken quickly to remedy this.

Case study 2: Practice nurses at Irlam Medical Centre in Manchester voluntarily organised an annual stroke awareness clinic at a local supermarket for the whole community and had been doing this for the last five years

Case study 3: Practice staff from Belgrave Surgery in Scarborough, North Yorkshire attended ‘freshers week’ at the university, where they offered on-campus health assessments for students who wished to register. Students also received health information packs and the practice also took part in health and well-being events at the university throughout the year, and worked in conjunction with the university counselling service.

Learning points:

  • Can you show that you have an understanding of your local patient population and highlight any initiatives that you have developed to address particular health concerns in your local area?
  • Can you demonstrate working with your PPG to improve patient experience?
  • Can you demonstrate awareness of local initiatives to improve patient outcomes?
  • Is your practice involved in any public health or screening initiatives?

Reducing referrals

Case study 1: One GP at Boundary House Medical Centre in Sale, Cheshire provided a free acupuncture clinic for patients with conditions such as musculoskeletal problems, migraines, fibromyalgia and chronic fatigue syndrome. Audits showed a 70% response rate with reduced referral rates to secondary care and a reduction in prescribing costs

Case study 2: The Village Medical Centre in Liverpool recognised that they had a higher rate of referrals to hospital for older people than might be expected. It therefore took steps to monitor referrals and to ensure that they were timely and appropriate by introducing a programme of audit.

Learning points:

  • What processes does the practice have for reviewing referrals and ensuring they are appropriate?
  • Does the practice know what its referral rates are as compared to other local practices?
  • Has any review of referrals generated learning or training needs?
  • What safety systems do you have in place to make sure referrals are received and patients get appointments particularly for urgent referrals?
  • Is the whole team aware of the local pathways or how to find out where to refer as needed?
  • Do you have an up to date locum pack, which provides details of referral pathways?
  • How do you induct new staff about referral pathways?

Supporting healthy living

Case study: Dr GAM Burnett and Partners in Reading, Berkshire had a strong focus on health promotion and self-care. The practice produced a detailed booklet describing a number of health promotion initiatives including ‘Health Walks’, ‘Green Gym’ (a gardening and conservation project) and a cycling club. The practice focused on encouraging and actively supporting patients to adopt exercise.

Learning points:

  • Can you give any examples of how the practice promotes healthy living?
  • Is the team aware of local initiatives around healthy living?
  • Is everyone aware of how to check if a patient smokes and how to refer to smoking cessation?
  • Are you asking all patients over 16 about their drinking and offering brief intervention where appropriate?

Working with external agencies

Case study 1: Orchard Court Surgery in County Durham works as part of an initiative to encourage people back to work. The practice hosted an employment support advisor from the Job Centre one day a week to provide advice on work related issues. The practice booked patients into the service and they demonstrated that it was having a positive impact.

Case study 2: St Paul’s Way Medical Centre in east London takes a systematic approach to working with others in the health and social care economy to improve care outcomes and tackle inequalities. The practice participates in a jointly funded social prescribing project in which they refer patients to wider support services, activities and programmes within the borough. The practice regularly engages with Public Health England and the community drug therapies team and provides weekly sessions for patients to meet with a benefits adviser.

Learning points:

  • Do you have any examples of working with external agencies to improve patient outcomes?
  • Are staff aware of what is available locally in the voluntary sector?
  • How do you communicate local projects and schemes so that staff are aware of them?

Fionnuala O'Donnell is a practice manager in Ealing, West London, and a CCG board member.

CQC definition of a practice rated outstanding for ‘Effective'

Outcomes for people who use services are consistently better than expected  when compared with other similar services.

There is a truly holistic approach to assessing, planning and delivering care and treatment to people who use services. The safe use of innovative and pioneering approaches to care and how it is delivered are actively encouraged. New evidence-based techniques and technologies are used to support the delivery of high quality care.  

All staff are actively engaged in activities to monitor and improve quality and outcomes.  Opportunities to participate in benchmarking, peer review and accreditation are proactively pursued. High performance is recognised by credible external bodies.

The continuing development of staff skills, competence and knowledge is recognised as  integral to ensuring high-quality care. Staff are proactively supported to acquire new skills and share best practice.

Staff, teams and services are committed to working collaboratively, people who have complex needs are supported to receive coordinated care and there are innovative and efficient ways to deliver more joined-up care to people who use services.  

The systems to manage and share the information that is needed to deliver effective  care are coordinated across services and support integrated care for people who use  services.

Consent practices and records are actively monitored and reviewed to improve how people are involved in making decisions about their care and treatment. Engagement with stakeholders, including people who use services and those close to them, informs the development of tools and support to aid informed consent.

Staff are consistent in supporting people to live healthier lives through a targeted and  proactive approach to health promotion and prevention of ill-health, and every contact  with people is used to do so.

Outstanding practice examples for other key questions

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