Newport Pagnell Medical Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

People were involved in decisions about their care and information was provided in a way that people could understand. The PPG delivered training sessions for patients on how to use online services, held monthly clinics in community venues and met regularly with practice representatives to review communications and access.

At our last assessment, we rated this key question as outstanding. At this assessment, the rating has changed to good.

This service scored 82 (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 ensured people were at the centre of their care and treatment decisions, working in partnership with them to respond to changing needs. Care plans reflected patients’ physical, mental, emotional and social needs, including those linked to protected characteristics under the Equality Act. Clinicians supported shared decision‑making by clearly explaining treatment options and long‑term condition pathways, enabling patients to make informed choices. For people with complex needs, families were included in Multi-Disciplinary Team (MDT) meetings and advance care planning to ensure personal wishes and consent were respected.

The provider gave examples of when they had ensured joined-up and sensitive person-centred care. These involved proactively identifying health and support needs of isolated patients and working across multidisciplinary teams to co-ordinate a plan of care. They ensured that relevant patients had transportation to appointments and communicated with carers and district nursing teams.

Representatives from care homes told us that clinicians involved the patient, staff at the home and families in care and treatment decisions. The practice also used patient feedback to drive service improvement. The PPG was proactive and had reviewed areas such as phone access and website usability, and the practice regularly considered Friends and Family Test and national survey results to shape service changes.

The practice demonstrated a strong understanding of the community’s diverse health needs and provided joined‑up, flexible care that supported choice and continuity. The differing needs of patients at each of the three sites was understood and factored into care delivery.

The practice had brought together the Integrated Community Support Team (ICST) and the Community Matron Team. This collaborative approach had provided proactive and holistic support for patients with complex health and social needs. The team was led by a senior nurse and included community matrons, a social work assistant, a care coordinator, an occupational therapist, a social prescriber, and a health and wellbeing coach.

The team aimed to improve patient health and wellbeing, promote independence, reduce hospital admissions and lessen frequent use of GP services. It identified unmet needs in the community through patient‑centred assessments, home visits, telephone support, and signposting to other services. The teams implemented person‑centred working, social prescribing and targeted interventions to reduce health inequalities.

The service supported patients with activities of daily living, medication management, learning disability annual health checks. High‑risk patients or those at risk of hospital admission were identified and monitored. It had also facilitated access to respite care, and undertook dementia support, memory assessments, over‑75s health checks, and carer support, helping patients to remain well and independent at home.

The practice was an Armed Forces Accredited Practice. All staff received relevant training on the needs of patients from the armed forces to ensure that they received timely referrals. The service had a clinical lead. These patients were reviewed at a quarterly matrix meeting.

The practice worked closely with external partners, including a local charity delivering weekly support groups for families affected by alcohol or drug use, and a digital health provider offering remote management of long‑term conditions such as asthma, and to support with medication, diet and exercise.

The practice offered a broad range of integrated services, hosting consultant‑led specialist clinics in urology, urogynaecology and colorectal surgery, alongside social prescribing services, health wellbeing coaches and cancer and carer support groups. Clear self‑referral routes enabled patients to access talking therapies, midwifery, physiotherapy and lifestyle services such as smoking cessation and weight‑management support.

Continuity of care was prioritised through a ‘Named GP’ model, ensuring each patient had a designated clinician overseeing results and hospital correspondence. Staff aimed to book follow‑up appointments with the same clinician wherever possible to support relationship‑building. People with complex needs had personalised management plans, and vulnerable patients were offered a dedicated bypass telephone number for urgent access. Families on the safeguarding register were allocated to the same GP to support holistic, coordinated care.

To address long waits for Child and Adolescent Mental Health Services, the practice commissioned a local charity (Artur Ellis) to provide 1:1 mental health and wellbeing support for children and young people aged 8–25.The average waiting time for Arthus Ellis mental health support was 4 days. It was reported that this was 277 days faster than NHS averages.

The service developed appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take up of screening and immunisation programmes was available in a range of languages. The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard. Patients were informed as to how to access their care records.

The PPG supported digital inclusion by delivering monthly NHS App training to patients within the local community.

The service was exceptional at enabling people to share feedback, ideas and complaints about their care.

The PPG was reformed in January 2025 to ensure active representation across all three sites. The PPG was highly engaged, with a partner attending each meeting. The group produced a monthly newsletter and made significant contributions to improving patient access through observations, data review, recommendations and implementation. PPG members were also integral to wider practice development and sat on the Equality, Diversity and Inclusion Working Group to help embed equality within everyday practice.

The PPG delivered training sessions for patients on how to use online services, held monthly clinics in community venues and met regularly with practice representatives to review communications and access. Individual PPG members held lead roles for Pharmacy First, online services, telephone access and communications, reviewing functionality, suggesting improvements and supporting implementation.

Complaints were managed in line with policy, and learning was clearly demonstrated. Staff could describe changes made as a result of feedback. The practice maintained multiple feedback channels, including the NHS Friends and Family Test, Accurx digital surveys and paper forms at reception. Information on the NHS complaints process was clearly signposted on the website and available from Patient Navigators or clinicians. Team leaders often resolved verbal concerns promptly to prevent escalation.

The practice had a strong track record of making tangible improvements based on patient input. Examples included replacing generic texts to patients with direct phone calls for urgent AE referrals, enhancing patient privacy by building a dedicated private room and increasing the number of same‑day appointments.

A ground‑floor patient consultation room was created in response to staff feedback highlighting the need for a private space for sensitive discussions.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The practice had identified through their own systems and processes, as well as the GP Patient Survey results, that patients were reporting significantly lower-than-average satisfaction with access. Alongside this, feedback indicated that patients were experiencing difficulty navigating the service. These issues prompted the leadership team to undertake a structured review of how the practice was operating.

The practice had taken part in the General Practice Improvement Programme (GPIP), a national NHS initiative delivered in partnership with the Royal College of General Practitioners, to address concerns about patient access and service pressures. Through GPIP, the practice examined its capacity in detail, reviewing appointment availability, call‑handling data and patterns of patient demand. This analysis helped the practice understand where bottlenecks were occurring and what changes were needed to make access more responsive and sustainable. Staff were fully engaged in the process, and the programmes’ structured support enabled the practice to identify practical adjustments that could be implemented quickly as well as longer‑term areas for improvement. The practice completed the programme last year and used the findings to inform its ongoing access strategy.

Robust plans were implemented to manage the contractual changes introduced on 1 October whereby NHS GP practices are required to keep appointments open and available throughout core working hours. The practice considered the operational implications of this change on day‑to‑day service delivery and implemented plans to manage the expected increase in demand. This included adding three additional locum clinicians to the duty rota to support the extended workload.

Requests for on the day appointments were managed by the Acute Hub. The triage GP was supported by three urgent care practitioners who were able to prescribe, 2 further GPs and an additional GP who provided end‑of‑day appointment capacity. These measures demonstrated the practice’s proactive approach to ensuring equity in access during the initial roll-out.

Extended appointments were available for people with a learning disability. People could access the service to suit their needs for example online, in person and by telephone. Treatment rooms were available on the ground floor and a ramp and automatic door had been fitted to the entrance.

Staff and leaders actively listened to people most likely to experience inequalities in access, experience or outcomes and tailored care and support to meet their needs.

GP Patient survey results highlighted areas requiring improvement, including the percentage of respondents who reported a positive overall experience of contacting the practice and those who found it easy to contact the practice by phone. These insights informed ongoing work to address inequities in patient experience.

Face‑to‑face appointments had increased year on year, with significant growth in 2025, demonstrating improved in‑person access. The practice continued to explore ways to enhance equity in access and experience. As part of this, they participated in the GPIP, which provided structured support to analyse capacity, demand and patient access patterns. The findings were then used to inform changes aimed at ensuring improved access for all patients.

The practice worked with local organisations, including voluntary sector partners, to tackle health inequalities within the community. Staff understood the importance of an inclusive approach and made reasonable adjustments to support equitable access and outcomes. Processes were in place to ensure people in vulnerable circumstances, including refugees, could register with the practice. Systems were also used to capture feedback from people who did not speak English or lacked internet access.

An Equality, Diversity and Inclusion Group was established to promote inclusivity and drive improvement. Membership included practice management, the PPG, the local Primary Care Network (PCN) Social Prescriber and the PCN Lead Care Coordinator. Guided by a Terms of Reference, the group identified priority areas such as patient and staff education and the development of actionable insights to ensure that the zero tolerance policy was adhered to.

A dedicated breastfeeding room was available on the first floor, and clinical rooms contained privacy screens. Chaperones were offered during examinations where needed, and patient preferences for a clinician of a particular gender were accommodated wherever possible to respect cultural and religious needs.

The practice held a weekly internal cancer matrix meeting as well as a monthly cancer and end‑of‑life multi-disciplinary meeting. The latter was attended by 2 GPs, the cancer‑lead pharmacist, a clinical quality team representative, a practice nurse and clinical nurse specialists from the local Hospice at Home team. The meeting reviewed patients on the Hospice at Home caseload, identified those deteriorating or approaching end of life and coordinated additional support.

Each matrix meeting also reviewed newly diagnosed cancer cases for practice patients. Cancer care review discussions were arranged with GPs, home visits were organised by GPs or nurses where required and referrals were made to the hospital wellbeing hub or the hospice.

We spoke with care homes that the practice supported about the practice’s involvement at the end of a patient’s life. They explained how staff were responsive and sensitive during discussions.

Clinicians provided dedicated health checks for patients with learning disabilities and managed complex surgical or trauma wounds. Housebound patients received integrated home visits delivered in collaboration with specialist nursing teams.