Great Barr Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved patients in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed patients’ care and worked with other services to achieve this.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from patients using the service was positive. 86% of patients that completed the National GP Patient Survey agreed that they felt their needs were met during their last GP appointment which was in line with the local average of 88% and the national average of 90%.

Patients felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked patients’ health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of patients’ wider health and wellbeing. The provider had effective systems to identify patients with previously undiagnosed conditions. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

Appropriate referral pathways were in place to ensure patients’ needs were met, and staff demonstrated the appropriate skills and training to carry out reviews where required.

The service always planned and delivered patients’ care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

At the last assessment in 2025, we found the systems in place to monitor patients’ health conditions were ineffective and needed strengthening to ensure all patients received the appropriate care and treatment. At this assessment we found significant improvements had been made. During the remote clinical review, we carried out a search to identify patients with asthma who had been prescribed 2 or more courses of rescue steroids in the past 12 months. The search identified 30 patients. We reviewed a random sample of 5 clinical records and found all patients had been treated appropriately, including management of symptoms and exacerbations in line with clinical guidance. Where ongoing review was required, patients were appropriately invited for asthma reviews, with evidence of follow-up and documentation in the clinical record. We found the practice’s systems supported proactive asthma care.

We reviewed the number of patients with a diagnosis of chronic kidney disease stage 4 or 5, who had not had the appropriate monitoring completed in the past 9 months. The search identified all patients with this condition had been reviewed appropriately. We found the practice ensured patients were regularly reviewed with effective long term condition management in place.

Further reviews of the clinical system identified patients with diabetes who had a HbA1c of 75 and over. The search identified 81 patients. We reviewed a random sample of 5 clinical records and found the appropriate reviews had been completed and ongoing monitoring was in place with follow-up arrangements clearly documented, except for 1 patient who required an up-to-date blood pressure reading. This was discussed with the clinical team and we received assurances that the patient had been contacted to attend for a review.

We carried out a clinical search on patients who had hypothyroidism and not received the appropriate monitoring in the past 18 months. We found all patients had the appropriate monitoring completed and were up to date with the recommended clinical reviews. Test results were reviewed and acted upon appropriately, with clear documentation in the clinical record. We found no gaps in the monitoring of patients and effective long term condition management in place.

The clinical leadership team were consistently reviewing clinical guidelines to ensure patients were receiving high quality personalised care.

DICE (Diabetes in Community Extension) clinics had commenced in June 2026 at the practice. The clinics were held as joint clinics with a diabetic consultant and the senior GP partner at the practice for the management of patients with poorly controlled diabetes.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance. Staff had access to local and national guidelines which could be accessed easily through online platforms with links to guidance also available through their clinical system. Updates to guidance were shared with all relevant staff at meetings and learning events. Clinical audits were conducted to ensure care was delivered in line with legislation and recommended guidelines.

The service worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services.

We saw evidence that regular meetings were held across the service, including clinical, non-clinical, partner, safeguarding, and governance meetings. The practice had held a range of structured consultant-led educational sessions between December 2025 and July 2026, covering a range of clinical areas, for example haematology, menopause and orthopaedics. Feedback from the practice team demonstrated a whole clinical team approach with secondary care expertise. This provided opportunities for the practice to seek advice outside formal referral routes when a clinical question arose. The practice had plans to build a new forum to further strengthen the learning events in place.

The practice maintained strong and effective relationships with stakeholders and partner practices within its Primary Care Network (PCN). The PCN supported the practice by providing links to social prescribers, pharmacists and a paramedic. The practice worked with other services such as consultants and community specialists to ensure continuity of care. Regular multi-disciplinary team (MDT) meetings were held to review areas such as end of life.

Staff told us that they had access to the information they need to appropriately assess, plan and deliver patients’ care, treatment and support and they had enough information to plan and refer patients and receive subsequent results and information following referral. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care was co-ordinated effectively.

Referrals to other services were monitored to ensure that appointments were booked for patients in a timely manner, for example, when patients were referred for suspected cancers.

Staff were supportive of each other to ensure they had access to the information they needed to appropriately assess, plan, and deliver patients’ care and treatment. To ensure staff were able to work together effectively, the practice adopted an open-door policy to encourage staff to speak up so that any queries were resolved to reflect a positive working environment.

The service supported patients to manage their health and wellbeing to fully maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

The practice demonstrated a commitment to innovation through the introduction of clinical led clinics. For example:

• The practice had devised chronic disease management clinics (CDM), which were held 2 afternoons per month. The clinics had recently been implemented to review patients with long term conditions that were poorly controlled. The clinics were led by a GP and supported by the pharmacy team. A CDM template had been formulated by the practice for use in the clinics. A list was prepared on a monthly basis of patients that would benefit from being seen in the clinics. The GP lead worked through the list and authorised a plan of action. The plans were shared with the pharmacy team who delivered the authorised plan to the patient in the clinic. Regular follow up appointments were organised to monitor the patient and review if any changes were required. At the time of the assessment, 67 patients had been seen in the CDM clinics. An audit had been completed of 10 patients to review the effectiveness of the clinics. The audit demonstrated 2 patients had been referred to the DiCE clinics (Diabetes in Community Extension) community service to support patients whose diabetes was poorly controlled. A total of 4 patients who had previously been non-compliant or had stopped statin therapy had following a review in the CDM clinic had restarted treatment and had blood tests scheduled in to confirm clinical impact. This approach shifted care from reactive to proactive management, with patients identified and prioritised based on clinical risk. Each patient received an individualised care plan, including medication optimisation, investigations, and structured follow-up.

The practice had been involved in a range of initiatives. This included:

• In August 2025, the practice had designed and delivered a breast cancer awareness event. The event formed part of the practice's ongoing cancer care and health promotion work, which aimed to raise awareness of the signs and symptoms of cancer, encourage timely presentation and screening uptake, and connect patients with local support and community services. The event was held on a Saturday to widen accessibility for working patients and their families and included an afternoon tea. The practice staff supported the event alongside community teams in providing information to patients. More than 50 patients attended the event and money was raised to support breast cancer awareness charity. Breast screening data showed the practice had seen an increase in the number of patients attending breast screening. For example, during 2023/24 760 patients had attended screening. During 2024/25 this had increased to 825 patients.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice had made reasonable adjustments to provide support to vulnerable patients. This included home visits for patients who were unable to attend the practice.

The service did not always achieve the national targets for screening and immunisations.

The practice was below the national target of 95% for all 5 of the national childhood immunisations targets. For example, 83.5% of children aged 2 who have received immunisation for measles, mumps and rubella (one dose of MMR). Patients that failed to attend appointments were followed up and information was shared with the health visiting team. The practice had implemented a named administrative immunisation champion, who had been trained specifically to manage recall and who maintained the immunisation registers and identified children who were due or overdue on a weekly basis.

The practice was below the national target of 80% uptake for cervical screening with the practice having achieved 61.9% for patients aged between 25 to 49 years of age and 66.7% for patients aged 50 to 64 years. To encourage patients to attend their appointments, appointments were available at different times throughout the week to provide choice and a range of availability. The practice had a structured recall system in place and opportunistic appointments were offered when patients attended the practice for other reasons.

The practice recognised that improving engagement with preventative care remained a significant challenge due to health inequalities within their patient population. Leaders demonstrated a clear understanding of the factors affecting uptake, including language barriers and digital exclusion, which impacted patients’ ability to engage with screening and immunisation programmes. To encourage patients to attend for screening the practice had held a breast awareness event to provide information to patients.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency. For example, there were audits for health inequalities in diabetes, high risk drug monitoring, asthma and weight management.

Although performance against some screening and immunisation targets remained below national expectations, the clinical records we reviewed demonstrated that individual patients generally received care and treatment in line with evidence-based guidance.

The service told patients about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.