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GP example: Staff and services working well together

  • Organisations we regulate

Key question: effective?

Holistic approach to delivering care

A suburban practice with over 11,000 patients.

This practice had taken part in local pilot schemes to improve outcomes for patients in the area. For example, the partners had taken a lead role in the design of care pathways for a range of long-term conditions. As a result, community services were developed to treat and manage conditions such as respiratory conditions, heart failure and cardiology, pain and non-malignant palliative care. Outcomes achieved for patients included services being delivered closer to home and a reduction in secondary care referrals and hospital admissions.

Additionally, it had an active patient participation group (PPG) which had strong links with the local community through facilitating health promotion events and local support groups for lung related health needs and carers. The PPG also worked in collaboration with two other PPGs to ensure the wider community benefitted from the activities they held.

By developing community services, this practice not only demonstrated improved outcomes for local people but also delivered what patients often care most about - having care closer to home.

Read our full inspection report (Church Walk Surgery)

Social prescribing

A practice in a deprived urban area with 3,000 registered patients.

The practice worked constructively with other community agencies to secure quality outcomes for patients. We saw that some patients who were suffering from anxiety received a prescription that stated financial problems as the cause of their anxiety, and prescribed advice from benefits advisers and debt counsellors to address the problems. The advice sessions identified that some patients had not been receiving their full benefit entitlement, and appropriate action was taken quickly to remedy this, which represented a further positive outcome for the patient.

Read our full inspection report (Dr Andreas Tobias Keyser)

Working with other agencies

A community interest company serving 10,500 registered patients in a deprived urban area.

The practice 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 advisor. The practice undertakes a number of health promotion activities both in house and in the community to enable patients and members of the public to increase their control over, and improve, their health.

The practice has forged strong links with external agencies in order to improve outcomes for patients’ health and wider wellbeing.

Read our full inspection report (St Pauls Way Medical Centre)

Last updated:
10 August 2017


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