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GP example: Planning services to meet people's needs
Key question: responsive?
R1: Are services planned and delivered to meet the needs of people?
Providing high quality additional services
An urban practice with 15,500 registered patients.
The practice nurses had worked with the dermatology department at the local hospital to receive training and advice. This included extended tissue viability training for practice nurses and health care assistants 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.
Because the staff had received this extra training, patients were able to receive more complex treatment at the practice. This service was over and above what was expected from the practice and had improved outcomes for patients.
Mental illness managed by the GP practice
A nurse practitioner-led practice with 4,400 patients in a deprived urban area.
The practice took part in a programme which supports patients with mental illnesses to access high quality, better coordinated care outside of hospital. It helps patients with common mental illnesses or stable severe and enduring mental illnesses to be cared for in the community. The practice demonstrated the impact of the program which had enabled 19 patients who were previously cared for in secondary care to be managed in the GP setting.
Identifying older patients at risk in the home
A suburban practice with 12,700 registered patients.
The practice identified patients who were aged 75 or over and vulnerable, and was involved in a partnership agreement between the local fire and rescue service and integrated neighbourhood teams. They cooperated to identify patients at risk of a home fire and to mitigate those risks as far as possible by offering a free home fire risk assessment. The practice was proactive in its approach to this scheme and achieved the highest take-up in the borough with 127 patients enrolled.
Improving access for different groups
The practice is one of a group of 25 GP practices and one walk-in centre, providing primary medical services to around 10,700 patients.
The practice demonstrated an outstanding commitment to improving access to patients from a range of different groups, including young people, those with language barriers and those with mental health problems.
The practice had developed a project called 'Practice Champions' aimed at parents and young people aged 16-21. The Practice Champions supported other patients through education, signposting and peer support. This had increased the number of young people who attended the surgery for general information as well as for specific concerns.
The practice formed a partnership with a local charity to improve access to primary care services for people whose first language was not English and had co-produced a short film with patients, clinicians and faith groups called 'Talking from the heart'; exploring mental health diagnosis and therapy by combining medical and faith advice.
Innovative care for young people
This practice serves approximately 40,000 patients, the majority of whom are of working age or students.
The leadership team and the practice had won several national and local awards in recognition of their innovative approaches to delivering high quality care. For example, an in-house musculoskeletal, physio and sports medicine service was developed in response to sports injuries linked to the student population, and a dermatology nurse led acne service was funded by the practice at an additional cost to them.
The practice took a proactive role in undertaking education and research linked to improving the well-being of patients experiencing poor mental health. The practice offered a weekly drop-in clinic for patients with mild to moderate eating disorders, and a series of six sessions of cognitive behavioural therapy specifically for students. This service was extended to another local university and is currently provided as part of the eating disorders in students service.
The practice had various systems in place to engage and communicate with its student population including a personalised feedback system whereby the practice manager encouraged direct patient feedback to him and an automated text and email messaging service to allow a fast and easy stream of communication.
Integrating health, care and community services
A practice in a deprived urban area serving 3,000 patients.
The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they were responsive to patients’ needs. Staff used innovative approaches to providing integrated patient-centred care. For example, the staff team included counsellors and focused care workers who provided social and medical care to patients who need this support. The focused care team organised social activities, such as weekly coffee mornings and craft classes, open days and boogie babies. They did this to build relationships with the patient population, reduce social isolation and help patients to learn new skills whilst keeping informal contact with the practice, which also helped to reduce inappropriate attendance at acute hospital services, such as walk-in centres or accident and emergency departments. Audits showed that after one year of receiving support from the focused care team, families presented 57% less often.
- Last updated:
- 10 August 2017