Newport Pagnell 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

Digital solutions were introduced to ensure patients received efficient, evidence‑based care, with all necessary checks completed in a single appointment. Weekly clinics run by an Advanced Urology Practitioner and a Specialist Women’s Health Physiotherapist reduced the need for hospital visits and a successful pilot enabled care homes to access patients’ digital medical records. Health and Wellbeing Coaches delivered significant improvements for patients with diabetes, chronic pain, and emotional wellbeing needs. There was a structured Fibromyalgia/ME/Chronic Fatigue programme as well as a pre‑diabetes programme which evidenced meaningful health improvements for participating patients. Staff involved people in decisions about their care, ensuring they understood their treatment plans and could give informed consent. Where patients lacked capacity, staff worked with those important to them and followed the Best Interests Policy. Assessments took account of communication, personal and health needs, and care was based on the latest evidence. Staff collaborated with all agencies to support good outcomes and smooth transitions between services. At our last assessment, we rated this key question as good. At this assessment, the rating has changed to Outstanding.

This service scored 88 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff made sure people’s care and treatment was effective by assessing their health, care, wellbeing and communication needs with them. Requests for appointments were triaged by an experienced triage team, and patients were directed to the most appropriate clinician.

Two Advanced Nurse Practitioners (ANPs) and 2 paramedics worked alongside the duty doctor to provide urgent, on the day care. Each member of the team was able to prescribe and see patients independently. Reception staff informed patients who they would be seeing and provided clarity, education and assurance on the roles.

The practice had effective systems to identify and prioritise care for vulnerable people. Feedback from patients was positive; they felt involved when clinicians assessed their needs, and confident that staff understood their individual and cultural requirements. Reception staff demonstrated awareness of the needs of the local community.

Reasonable adjustments were in place, including provision of a hearing loop, interpreter services and large‑font materials. Enhanced access was available for vulnerable patients, and the Oliver McGowan learning disability and autism training was completed by all employees. Patient records contained flags to highlight relevant information to clinicians.

Systems were in place to identify people with caring responsibilities at registration, opportunistically and through self‑reporting.

Staff reviewed people’s health, care and wellbeing needs during routine assessments. Staff could refer people with social needs such as isolation or housing concerns to a social prescriber. (A social prescriber is an individual who helps patients address non-medical, social, emotional or practical needs).

Practice staff planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Clinical records we saw demonstrated care was provided in line with current guidance.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. This included through the internal compliance system, dedicated training days and clinical meetings.

The practice actively involved patients when prescribing a new treatment to lower cholesterol. This was to ensure they were aware of why they were being offered the medicine, along with any associated risks. A new clinical pathway was embedded, supported by a system of regular audit.

Digital solutions were implemented to ensure patients received evidence-based, efficient care. For example, a system was implemented to ensure that when patients required multiple tests from various providers or for multiple conditions, these could be completed in a single appointment rather than across several separate visits. Effective processes were introduced to ensure all clinicians understood how to use the new system, including the delivery of a presentation and the provision of drop‑in support sessions.

Practice staff collaborated effectively across various teams and services to support patients. This teamwork helped reduce duplication, prevented treatment delays and ensured people received consistent, continuous care.

Staff had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

An Advanced Urology Practitioner and a Specialist Women’s Health Physiotherapist provided weekly clinics for male and female patients with urinary symptoms, including prostate assessments, support for female urinary incontinence and diagnostic investigations. These services were available to all patients in the locality on Tuesdays and Wednesdays and offered specialist urology care outside of a hospital setting. The clinic saw 1,079 patients last year, enabling patients to be managed effectively in the community rather than in secondary care.

The practice maintained close connections with Milton Keynes Community Team for Adults who have a Learning Disability (CTALD) and information regarding patients was securely exchanged through an internal portal. The practice worked with other services to ensure continuity of care, for example for people with palliative care and end of life needs. The practice has effective communication with the local Hospice who attended the monthly cancer matrix meeting.

Care home representatives explained the joint working arrangements with the practice. They told us that they were updated when there was a change to a patient’s care and treatment. Following a successful pilot, there were digital systems in place to enable care homes to see the patient’s digital medical record.

Matrix meetings were held on various days to review and update on clinical and administrative areas, such as Cancer, Diabetes, Anticoagulation, Immunisations and Vaccinations, Mental Health, Prescribing, Respiratory, Safeguarding (adult and children), Sexual health, Vascular and Veterans. This promoted a Multi-disciplinary approach and cross-working across the practice.

Through the Mental Health Matrix meeting, a comprehensive directory of key services was implemented.

Practice staff supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support.

There were a wide range of services to support patients to live healthier lives. These services were delivered at home, in the community and at the practice itself. Services included adult hearing checks, community eye services, drug and alcohol family support, cancer care, a carers group, a men’s mental health group, physiotherapy, weight‑loss support, stop‑smoking services, podiatry and social prescribing.

The practice operated a weekly drop‑in clinic for patients experiencing problems with their legs, for example ulceration. This was led by the practice nurse and district nursing teams and supported by volunteers.

Health and Wellbeing Coaches were available at the practice, delivering measurable and significant improvements across multiple patient groups, including those with diabetes, chronic pain, and emotional wellbeing needs in both children and adults. Health and Wellbeing coaches conducted 66 face‑to‑face appointments in the past year, as well as 222 one‑to‑one sessions. Services included one‑to‑one art‑based therapy for children in local primary schools, typically across six sessions to support improved mental health. Work with a local charity further strengthened provision, with data showing improvements in empathy, motivation, self‑awareness, self‑regulation and social skills. Feedback from parents reflected the impact of the service, including comments such as: “The support my child has been given is nothing short of brilliant. The service you have provided is life‑changing.”

The practice also delivered a structured Fibromyalgia / ME / Chronic Fatigue Syndrome programme over six to nine sessions. This incorporated art therapy, fatigue management, pain understanding, improvements in sleep quality, anxiety and low‑mood support, and techniques to improve cognitive clarity and reduce brain fog.

Staff routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent and that they met both clinical expectations and the expectations of people themselves. From the clinical notes we reviewed, we found people experienced positive outcomes as set out in legislation, standards and evidence-based clinical guidance.

A pre‑diabetes clinic programme was initiated, offering online group sessions for patients at risk of developing diabetes. It began as a 12‑week pilot and was later continued, providing evening online sessions and support, access to blood tests and use of continuous glucose monitors. A WhatsApp group was created after each programme to maintain peer support. Of 100 patients invited, 24 participated in the first pilot and 30 in the second, with all completing the full course. The practice found that continuous glucose monitoring strengthened patient engagement and that evening sessions improved access for those unable to attend during the day. Data we saw demonstrated that the majority of participants lost weight during the programme, and blood testing indicated that they had also improved their diabetes control. Feedback indicated that 26 out of 33 responders felt that they had a better understanding of their diabetes.

The practice worked with the council to deliver menopause support sessions at a local community centre. This included health promotion advice and support, as well group discussions over a 5-week period. We reviewed 5 feedback forms. All of these were very positive and said that they would recommend the sessions.

The practice achieved the World Health Organisation target of 95% for 2 of the childhood immunisation indicators. There were measures in place to improve the uptake of cervical screening, as this was below the 80% screening tests provided to eligible women within a given timeframe.

The practice had a comprehensive programme of clinical and non-clinical audits to monitor, review and improve patient outcomes. These included single-cycle and multi-cycle audits as appropriate and were completed across the team. Learning was shared to continually improve patient outcomes.

Staff told people about their rights regarding consent and respected these when delivering person-centred care and treatment. The practice maintained clear systems to obtain consent for care and treatment, fully aligned with current laws and guidance. Specific policies were in place to assist staff in securing consent from adults and children, as well as making best-interest decisions for those who lacked mental capacity. Staff we spoke with had a good understanding of consent and staff had completed training on consent and the Mental Capacity Act

Clinicians supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to make a decision and involved relevant people and advocates as appropriate.

Chaperone information was displayed in the practice and on the website. Chaperones received in-house training.

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