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Blossoms Healthcare LLP - Garlick Hill Good

Inspection Summary


Overall summary & rating

Good

Updated 19 August 2019

This service is rated as Good overall. The service was previously inspected in February 2018 and found to be meeting requirements for all domains.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Blossoms Healthcare – Garlick Hill on 27 June 2019 as part of our inspection programme.

The provider supplies private general practitioner services predominantly to staff employed by corporate clients. The provider also provides services to private fee-paying patients.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At Blossoms Healthcare Garlick Hill, approximately 90% of patients are treated under arrangements made by their employer. These types of arrangements are exempt by law from CQC regulation. Therefore, we were only able to rate the services which are not arranged for patients by their employers. However, some of the evidence quoted in the report regarding the quality of fee-paying patient outside of this exemption stems from evidence of care provided to exempt patients as this was used to demonstrate the general quality of care provided to all patients using the service.

The provider is in the process of registering a new registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received 12 CQC comments cards. All comment cards were positive with patients referring to the high standard of care provided by knowledgeable and supportive staff.

Our key findings were:

  • The provider had systems in place to keep people safe and to review, act and learn from significant events. We reviewed examples where the provider had made contact with the patient’s NHS GP to pass on information that was clinically necessary with the patient’s consent. We were told that, when necessary to ensure patient safety, the service would contact the patients NHS GP without consent.
  • There were processes in place to effectively handle emergencies and risks were managed appropriately. Recruitment checks had been completed for the staff whose files we reviewed.
  • Systems were in place for the safe management of medicines and we saw the provider had processes in place to review prescribing. Following a recent inspection at another of it’s registered locations, the provider had developed plans to undertake regular reviews of antibiotic prescribing.
  • Staff at the service assessed patients in accordance with best practice and current guidelines and had systems in place to monitor and improve the quality of care provided to patients.
  • There was evidence of effective joint working and sufficient staffing to meet the needs of their patient population.
  • Feedback indicated patients were treated with dignity and care and the service had systems to support patients to be involved with decisions about their care and treatment.

  • The service met the needs of their targeted patient demographic and there were systems in place for acting on feedback and complaints.
  • The service had adequate leadership and governance in place.
  • There was clear strategy and vision which was tailored to patient need and staff and patients were able to engage and feedback to the service provider.

The areas where the provider should make improvements are:

  • Follow through with plans to review antibiotic prescribing to assess the extent to which the service is following best practice and guidance.
  • Continue to review and assess emergency medicines kept on the premises to ensure decisions are justified and reflect the treatments provided and the patient groups who use the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 19 August 2019

We rated safe as

Good because:

The provider had systems in place to keep people safe and to review, act and learn from significant events. There were processes in place to effectively handle emergencies and the use of medicines and risks were managed appropriately.

Safety systems and processes

The service

had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate for most staff. Disclosure and Barring Service (DBS) checks were undertaken for all staff whose files we reviewed. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Although the provider did not see children under 18, all staff whose files we reviewed had received child safeguarding training.
  • Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control including quarterly infection prevention and control audits.
  • The service ensured it received and kept a copy of legionella risk assessments undertaken by the building’s management company and would follow-up if actions were recommended.
  • The provider ensured facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. The provider had commissioned a specialist training provider to deliver cardiopulmonary resuscitation (CPR) training using an interactive training mannequin which provided staff a practical simulation experience.
  • The provider had emergency equipment available including oxygen and a defibrillator. The provider did not have a supply of all recommended emergency medicines but had undertaken a risk assessment of the medicines they did not keep on the premises which justified their absence as they do not perform treatments or see patients that would require these medicines.
  • Although the service did not offer consultations to paediatric patients, it recognised the possibility that patients attending the service could be accompanied by their children who could become ill whilst on the premises. The provider had assessed the risk associated with this eventuality and ensured emergency equipment included paediatric fittings.
  • When there were changes to services or staff, the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities. The provider had a group medical indemnity policy which covered the activities of all staff providing regulated activities.

Information to deliver safe care and treatment

Staff

had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were maintained in electronic format and written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • Following a recent inspection at another of it’s registered locations, the provider had undertaken a two cycle audit of contraception and anti depressants to ensure the prescribing of these medicines was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.

Track record on safety and incidents

The service

had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • The provider used an electronic system for recording and acting on significant events. This enabled incidents to be viewed by senior management within HCA Healthcare and learning shared across the organisation. We were told the system used a colour coding system which meant recorded incidents appeared in red until all stages of the significant event process had been completed, including identification and embedding of learning points. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and acted to improve safety in the service. For example, the service had recorded an occasion when the ambient temperature in a storage room in a different registered location had elevated to a point where the integrity of items stored in the room could have been affected. As a result of this incident, the service updated its cold chain policy so that staff were clear on the action to take if this happened again. The provider had applied the learning to this location by installing second fridge thermometers and room temperature monitors and developed a procedure to transfer stored items between rooms to mitigate against the risk of any medicines or equipment being adversely affected by high temperatures.
  • The provider was aware of and had systems in place to ensure compliance with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service had systems in place to ensure affected people received reasonable support, truthful information and a verbal and written apology
  • The provider would keep written records of verbal interactions as well as written correspondence.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. We saw records showing actions taken as a result of alerts as well as evidence showing audits undertaken to identify patients affected. We noted these were repeated over time to ensure patients new to the service were also assessed to check whether they might be affected by previously issued alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team.

Effective

Good

Updated 19 August 2019

We rated effective as

Good

because:

Staff at the service assessed patients in accordance with best practice and current guidelines and had systems in place to monitor and improve the quality of care provided to patients. There was evidence of effective joint working and enough staffing to meet the needs of their patient population.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The service was arranged in a way which supported continuity of care for repeat patients.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity

  • The service had received SEQOHS accreditation in 2018 which is an accreditation for providers of occupational health services. They had also achieved International Organisation for Standardization accreditation in respect of the quality of service it provides and for adherence to information security standards.
  • The service made improvements using completed audit cycles. The provider had recently improved the IT system which enabled them to undertake regular audits and we saw evidence these audits had a positive impact on quality of care provided. There was clear evidence of action to resolve concerns and improve quality. For example, the service had recently reviewed their repeat prescribing to ensure that clinicians were undertaking annual reviews for patients. In the most recent audit the service had an 89% compliance rate. The service had also reviewed patients prescribed with a non-steroidal anti-inflammatory drug (NSAID) and found that four out of five prescriptions issued for this medicine between January and April 2019 adhered to NICE prescribing for this class of medicine. The service had also audited contraceptive reviews to ensure the necessary components of the review were being completed by staff during consultations. Between the first cycle in 2017 and the second cycle in 2019 the percentage of patients who had their BMI calculated and blood pressure checked had improved by 35% and 4% respectively. The service also audited the prescribing of antidepressants.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. The service was part of a larger healthcare organisation and had access to that organisation’s internal training and learning academy. In addition to being directed to mandatory training, staff could access a range of additional, optional training opportunities. Up to date records of skills, qualifications and training were maintained and we noted the provider used a colour coded matrix to highlight when training renewal dates were approaching. Staff were encouraged and given opportunities to develop.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • The provider had recently introduced a ‘GP Concierge Team’ to improve how patients received coordinated and person-centred care. This team supported both clinicians and patients to communicate effectively with, other services when appropriate. For instance this team maintained a directory of specialist care providers and consultants and could advise GPs who wanted up to date information when making referrals. We were told this was particularly helpful to newer clinicians who did not yet have overarching knowledge of the wider healthcare landscape.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment.
  • Staff at the service told us that they would share details of consultations with the patient’s NHS GP without their consent if this was clinically necessary or needed to keep the patient safe. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.
  • The service had developed an app and an online portal which enabled patients to access test results, medical reports and some of the patient’s consultation records which they could share with their NHS GP or other healthcare providers.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support including patients NHS GP or secondary care services.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs, inlcuding to NHS services where this was in the patient’s best interests.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Caring

Good

Updated 19 August 2019

We rated caring as

Good

because:

Feedback indicated that patients were treated with dignity and care and the service had systems to support patients to be involved with decisions about their care and treatment.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. We received 12 CQC comment cards. All comment cards were positive with patients referring to the high standard of care provided by knowledgeable and supportive staff. The service had also undertaken their own internal survey. Patients were sent an email prompting them to complete the survey after each appointment. Between March 2019 and June 2019, 85% of 47 patients who responded rated their experience with the provider as good or very good and 83% of 46 patients said that they were likely or extremely likely to recommend the service to a friend. At the time of our inspection, the provider was reviewing these results to identify where further improvements could be made.

  • Staff displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. We saw information in the reception areas about this service. The service also had a hearing loop and had recently begun to provide information about the service in braille.
  • Patients told us through comment cards, they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • The service told us they did not frequently see patients with learning disabilities or complex social needs but that if they did the family, carers or social workers were appropriately involved.
  • Staff communicated with people in a way they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 19 August 2019

We rated responsive as

Good

because:

The service was designed to meet the needs of fee-paying patients who wanted quick same day access to care and treatment and the service had systems in place for acting on feedback and complaints.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. The provider held contracts with large corporate clients and most of the patients who attended the service worked at these companies. Services were designed to meet the needs of this group to ensure they had fast access to care when required. This also benefited and appealed to private fee paying patients. For example, blood samples were collected twice daily. Any results that required urgent action would be sent to the service during opening hours and to the on-call doctor when the service was closed who could contact the patient and arrange the appropriate follow up.
  • The facilities and premises were appropriate for the services delivered.
  • The service had identified an increase in patients reporting domestic violence and there was now an organisation wide domestic violence working group. From this the provider had increased awareness of the issue among all staff and had introduced systems to enable staff to discreetly provide victims with contact information for support organisations.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, there were wheelchair accessible facilities, a lift and a hearing loop.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately. The service monitored their waiting times. Between May 2018 and April 2019 30% of patients were seen within five minutes of their appointment time and 9% were seen before their appointment time. The service’s clinical system indicated that 22% of patients waited over 15 minutes to be seen when they arrived for their appointment. We were told this was likely the result of clinicians not recording the patients as having arrived before they started their consultation which account for this percentage being higher than staff anticipated. The service monitored call pick up times. In 2019 between 81 and 87% of calls were answered within 30 seconds. The proportion of calls answered against those lost was also monitored. In 2019 between 92 and 95% of calls were answered.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported the appointment system was easy to use. The provider had developed an app/online portal that enabled them to book appointments easily online. The app enabled patients to specify the GP or the gender of the GP they wanted to see. Appointment reminders would then be sent to patients using the app.
  • Referrals and transfers to other services were undertaken in a timely way. For example, the provider had links to local private hospitals that were part of the same organisation which enabled patients who required further assessment or treatment to be seen quickly by an appropriate clinician.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had a complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, in response to a complaint related to issuing incorrect correspondence, the provider had implemented a backup checking system where administrative staff would double check patient details and make note of this check prior to issuing sensitive information.

Well-led

Good

Updated 19 August 2019

We rated well-led as

Good because:

The service had adequate leadership and governance in place. They had a strategy and vision which was tailored to the needs of patients they catered to and staff and patients were able to engage and feedback to the service provider.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • There was a clear leadership structure within the organisation. Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. For example, the service had enrolled the incoming registered manager on an internal leadership programme.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • The provider described their vision as ‘to provide exceptional care using exceptional people’ and we saw it had a supporting set of values including recognising patients as unique individuals and acting with honesty and integrity. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff. The service provided staff with access to a ‘wellness calendar’ which showed positive actions a person could take to improve wellbeing. Staff had access to an employee assistance helpline offering confidential counselling and advice for personal, family or workplace issues.and the service also had a scheme which recognised long service and staff who had excelled in their role.
  • The service promoted equality and diversity. It identified and addressed the causes of any workforce inequality.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • There was a clear governance structure and staff were clear on their roles and accountabilities .
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audits. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

  • The service used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the patients, staff and external partners and acted on them to shape services and culture. For example, the service obtained feedback from patients using an online survey which patients were invited to complete after their consultation.
  • Staff told us that they were able to raise concerns and give feedback.
  • The service was transparent, collaborative and open with stakeholders about performance. We were told senior clinical staff sat on Medical Advisory Boards at some of their largest clients and used this as an opportunity to encourage businesses to take an innovative and proactive approach to health screening. For instance, it had worked with one client who was engaged in a fast paced business environment, to introduce cervical and breast screening programmes for employees who found it difficult to engage with national screening programmes.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements. For instance, the provider had identified a risk pathology results might not being reviewed in a timely manner because the system in place relied on the clinician having to remember to check whether results had been returned. The provider had changed to a new electronic medical record system which included a feature that ensured an alert was sent to the requesting clinician when results were returned. The alert was also sent to a senior clinician who would ensure the result was reviewed and appropriate action taken. All GPs had remote access to patient notes.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

  • There were systems to support improvement and innovation work. The provider had developed an app which enabled patients to access their medical record. The app also allowed patients to book and pay for appointments online and enabled patients to choose a specific GP.