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GP example: Taking account of the needs of different people
Key question: responsive?
R2: Do services take account of the needs of different people, including those in vulnerable circumstances?
Supporting older people
A nurse practitioner-led practice with 4,400 patients in a deprived urban area.
The practice worked hard to improve the coordination of care for older people. An Age UK support worker attended the practice three days a week to support older patients who live alone. The practice also provided transport to improve access for those patients who are house bound or find it difficult to get to the surgery. Patients reported satisfaction and liked being supported to attend the surgery. This has improved socialisation and reduced the number of home visits by 20 during its first month.
Engaging with children and young people
A practice in a rural area serving 11,000 registered patients.
The practice had an outstanding approach to the care of children and young people. They actively promoted the ‘You’re Welcome’ initiative - a Department of Health quality initiative to ensure health services are young people friendly. The practice had leaflets displaying the services offered and how to access them in appropriate formats for young people. It also had an explicit policy and information on confidentiality and consent relating to young people.
The practice also ran its own young person’s (13 to 19 year old) questionnaire. The results of this showed that all participants would recommend the practice to others, felt staff were welcoming and friendly, and felt able to ask questions. Improvements were made to increase the response rate, to improve the explanation of confidentiality for young people, and to clarify who young people could bring to consultations. Facebook and Twitter accounts were actively promoted by the practice to maximise interaction with young people about their health and medicines.
Using new technology to improve access
A practice in a small town with 12,200 registered patients.
The nurse practitioner offered open access by mobile phone to teenagers with diabetes who were insulin dependent. They were able to text their blood test results if they had any concerns about managing their diabetes and the nurse practitioner would respond.
This is an outstanding example of innovative practice to respond flexibly to the needs of the younger population.
Championing care for people who have a learning disability
A suburban practice with 10,000 registered patients.
The practice had outstanding services for people with a learning disability and performed better than other practices nationally for QOF indicators relating to learning disability.
The practice had taken the lead role in influencing the care provided by neighbouring practices, by working with the local CCG as well as other CCGs in the region. One of the GPs had developed a ‘ready reckoner’ for common conditions associated with learning disability. The template was used by the CCG and there were easy read leaflets on the website. The practice had also looked at this group of patients to determine the number of ‘do not attend’ appointments. The learning disability register was cross-checked in order to help people with a learning disability through the health care system.
The lead partner also helped other practices by giving advice about setting up their own services.
Healthcare for people excluded from mainstream services
An urban practice with 4,500 registered patients.
The practice is open from 8am to 8pm every day, including Sundays, bank holidays and Christmas day. The practice provides services to patients who are on the special allocation scheme. This scheme is for patients who have been removed from other practice lists because of behaviour that other practices have deemed unacceptable, for example the threat of verbal or physical abuse. This service is available three designated mornings a week and the appointments are for 30 minutes.
The practice has worked with the Salvation Army to provide medical care and health advice to homeless patients. This includes a health care assistant (HCA) attending the Salvation Army weekly to see if any homeless patients need medical care or health advice. If medical care is needed, the HCA arranges for a GP to visit. In addition, medical-related correspondence for a patient who is homeless is sent to the Salvation Army if that patient consents.
Outreach to people who are homeless
This surgery provides GP primary care services to approximately 1,700 homeless people.
The practice had a medical outreach project where GPs and practice staff would carry out night walks through the local streets and parks. They spoke with people sleeping rough to identify their medical needs, to improve their general health and their ability to access services.
The practice employed an in-house drug and alcohol counsellor who would see both booked and walk-in patients, and ran a bespoke Hepatitis C clinic.
The practice had an exceptionally high prevalence of patients with severe mental illness and personality disorder. They had entered into partnership with a service which places psychiatric nurses and doctors in general practices to increase their engagement with people with mental health problems. The practice had a part-time consultant psychiatrist, a community psychiatric nurse and an in-house counsellor.
The practice also provided services for 'failed' asylum seekers and undocumented migrants.
This practice used innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs.
Improving access by working closely with local charity
A city centre practice with approximately 8,400 patients
The practice was working hard to ensure that vulnerable groups in the community were not excluded from access to quality care. The staff worked closely with a local service that provided support for people who are homeless, or those at risk of being homeless, sex workers, prisoners and ex-offenders, people who substance misuse, travellers and asylum seekers). A partner at the practice was the lead GP at the service and approximately 30 patients had successfully moved from the City Reach programme to the practice for their ongoing care.
The practice also supported a local registered care home for people who have experienced homelessness and who have both mental health and substance abuse issues. Staff supported the care home team by providing routine GP primary care services and by a rapid medical response of advice and input, either in the surgery or the care home, within the hour, whenever a medical, mental health or behavioural crisis occurred.
Improving healthcare for people in hostels or homeless
An urban service offering primary health care to people who are homeless including residents of five hostels.
The practice had a clear ethos to improve the health of people who are vulnerable and excluded groups. Patients were very positive about the care and treatment they received. We saw many aspects of outstanding care, including:
The practice had a clear ethos to improve the health of people who are vulnerable and those in excluded groups. Patients were very positive about the care and treatment they received and we saw many aspects of outstanding care. All patients received a comprehensive health check on first registering with the practice, this helped to identify health and social care needs early. Appointments were for a minimum of 20 minutes to accommodate the more complex needs of patients. Volunteers supported patients by encouraging those who might not want to attend. All staff were involved in planning care and treatment at daily team meetings, ensuring a co-ordinated approach to meeting patients’ care and treatment needs.
The services included on-site podiatry and dentistry, which helped people access these services and staff visited homeless patients in remote locations to deliver care.
An award-winning patient participation group involved homeless patients through surveys, and the feedback helped to change the way services were delivered
- Last updated:
- 10 August 2017