Eve Hill Medical Practice

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• 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 people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Outstanding. At this assessment, the rating remains the same.

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.

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

96% of patients that completed the National GP Patient Survey data agreed that they felt their needs were met during their last GP appointment which was higher than the local average of 88% and the national average of 90%.

Feedback from people using the service was positive. People 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. All staff had completed learning disability and autism training.

Standard appointments were 15-20 minutes and patients with complex health needs were given longer appointments to review their needs. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The practice took a proactive approach to analysing its patient population, using health management tools to monitor and respond to changes in patient need. Systems such as reasonable adjustment digital flags were in place to support personalised care.

The practice identified a cohort of frequent attenders, consisting of 179 patients (2% of the practice population) who had attended 13 or more acute appointments within a 12-month period. This group accounted for 3,015 appointments, equating to approximately 58 appointments per week and representing 13.3% of total clinical capacity. This demonstrated that a small proportion of patients were utilising a disproportionate level of resources. In response, the practice implemented a structured and proactive approach, including the use of continuity of care flags, protected continuity appointment slots, and partnership working with the social prescribing team to provide more coordinated and personalised care. These interventions aimed to address underlying needs and reduce avoidable demand. Post intervention showed a 22% reduction in acute appointments over a 3-month period. Further population analysis also identified that 8% of registered patients had 3 or more long-term conditions.

Care plans and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records were completed and reviewed regularly. The provider had effective systems in place to identify patients with previously undiagnosed conditions. Systems were also 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, with 95% having received a review within the last 12 months. Reviews for long-term conditions were also carried out for patients who were housebound.

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 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.

Systems were in place to ensure staff remained up to date with legislative requirements and best practice guidance. Clinical records demonstrated that care was generally delivered in line with current recommendations.

Remote clinical searches identified that 9 of 412 patients with hypothyroidism (a condition in which the thyroid does not produce sufficient hormones) had not received appropriate monitoring in the previous 18 months. A review of 5 records showed that 2 patients had received appropriate monitoring, 2 had been recalled, and 1 remained overdue.

Further searches identified that 78 of 742 patients with diabetes had consistently elevated HbA1c (blood glucose) levels. A review of 5 records demonstrated that all patients had been appropriately followed up and managed.

In relation to asthma care, 25 of 724 patients had been prescribed two or more courses of rescue steroids in the previous 12 months. Of the 5 records reviewed, 4 patients were managed appropriately. One patient was overdue for monitoring; however, this was promptly addressed by the practice during the assessment. The practice advised that they had signed up to the local Spirometry Enhanced Service and had been actively engaging with the secondary care Difficult Asthma Service since February 2026 to support patients with more complex needs. Furthermore, the practice was in the process of embedding a new IT system to support patient recalls.

Evidence provided by the practice showed a proactive approach to improving asthma management. For example, in the last 12 months treatment had been stepped up in 34 patients, a further 43 patients had optimisation of existing therapy, 53 patients were no longer reliant solely on short-acting reliever inhalers, and an additional 55 patients had been initiated on Anti-Inflammatory Reliever (AIR) and Maintenance and Reliever Therapy (MART) in line with current guidance.

Staff had access to both local and national guidelines through easily accessible online platforms, with direct links also embedded within the clinical system. Updates to guidance were shared through meetings and learning events, and clinical audits were undertaken to ensure care remained aligned with legislation and recommended practice.

We discussed with the practice that in some instances minimal information was contained in the patient records or when medication reviews were undertaken. The practice explained that more comprehensive consultation notes were often documented elsewhere within the clinical system, including in an additional tab. However, the practice acknowledged that the rationale and broader clinical context were not always immediately visible within consultation entries. In response, they had reviewed their processes and taken steps to ensure that key management decisions and the supporting rationale are recorded more clearly and prominently within consultation records wherever possible.

The practice had also recently implemented an automated electronic recall system to support the management of long-term condition reviews, as well as recalls for shared care, repeat, and follow-up blood tests.

The practice always worked well across teams and services to support patients. They shared thorough assessments of patients’ needs when they moved between different services, so patients only needed to tell their story once.

We saw evidence that regular meetings were held across the service, including clinical, nursing, non-clinical, partner, safeguarding, and quality and safety meetings. In addition, quarterly learning events were held for all staff. These arrangements supported direct engagement across the whole team and provided opportunities for all staff to contribute their views. The sessions were also used to communicate the practice’s strategy and vision, support staff in working towards shared objectives, and provide ongoing training and development.

The practice maintained strong and effective relationships with stakeholders and partner practices within its Primary Care Network (PCN), where it held the role of lead practice. The PCN supported the practice by providing links to First Contact Physiotherapist, Health and Wellbeing Coach, Listening and Guidance, Occupational Therapist, Dietician, Migrant social prescriber, first contact mental health practitioner, Pharmacists and Physician Assistant. 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 diabetes, respiratory, end of life care and frailty.

The practice demonstrated an effective approach to partnership working with secondary care, underpinned by strong clinical and strategic collaboration. This included active participation in joint multidisciplinary team (MDT) meetings, shared management of patients with complex needs, and consistent, high-quality communication between primary and secondary care clinicians to support continuity and safety of care. Evidence reviewed included diabetes case studies, which demonstrated how collaborative working had led to measurable improvements in patient care and outcomes.

Furthermore, the practice played a proactive and influential role within the Black Country Integrated Care Board (ICB), contributing meaningfully to the development and delivery of system-wide programmes. Its involvement spanned key strategic priorities, including digital transformation, tackling health inequalities, workforce development, and improving patient access, demonstrating a clear commitment to system leadership and continuous improvement in patient outcomes.

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 people’s 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 consistently supported people to manage their health and wellbeing, enabling them to maximise independence, choice, and control. It promoted healthier lifestyles and aimed to reduce future care and support needs through a proactive and preventative approach.

Staff maintained a strong focus on identifying risks to patients’ health, including those approaching the last 12 months of life, individuals at risk of developing long-term conditions, and those with caring responsibilities. The practice actively supported national priorities to improve population health, including smoking cessation and tackling obesity. For example, 96% of eligible patients were offered smoking cessation advice, with 37% accepting a referral to support services. In addition, following a targeted campaign to capture body mass index (BMI) data, 98% of patients were offered weight management advice, resulting in 13% being referred to weight management services.

The practice demonstrated a commitment to innovation through the introduction of a virtual hypertension clinic model, led by a GP Partner and supported by a Healthcare Assistant. 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. Flexible options for blood pressure monitoring were offered, including home readings, in-practice checks, paper-based recording, and support from community pharmacies. To further reduce barriers, the practice introduced a blood pressure monitor loan scheme, with over 180 monitors issued in the previous 12 months. A total of 1,074 patients submitted home readings (12.1% of the practice population), representing a 31% increase in monitoring compared to the previous year. The programme showed clear improvements in blood pressure (BP) control. Patients with very high starting levels (≥160/100 mmHg) had noticeable reductions after treatment.Overall, 88% of eligible people with hypertension reached a BP below 140/90 mmHg in 2025/26, showing strong control across the population.

The practice also identified a high prevalence of elevated cholesterol within its population and responded by introducing Inclisiran injections for eligible patients, in line with national guidance (Inclisiran is a cholesterol lowering treatment that reduces levels of cholesterol). Clear clinical pathways were established, including patient identification, initiation criteria, and structured follow-up. A comprehensive training and competency framework supported safe delivery, and the pathway was embedded within the wider long-term condition and cardiovascular prevention programme to ensure holistic care.

Staff actively signposted patients to local services offering information, education, and tailored advice to support individual needs. Patients were encouraged to engage in national health initiatives, such as cancer screening programmes and childhood immunisations. The practice could evidence that they had completed 396 NHS Health Checks in the past 12 months. Overall, 55% of eligible patients had received a health check within the last 5 years, exceeding the England average of 34–39%. In addition, 93% of patients aged over 40 years had their blood pressure monitored within the same period.

The practice has also strengthened support for vulnerable patients by working in partnership with a dedicated migrant social prescriber. In the last 12 months, 67 patients were referred for support, including assistance with registration into primary care services.

The practice had a number of designated leads with specialist knowledge, including roles for carers, cancer, learning disabilities, veterans, patient safety, dignity, research, and an NHS App ambassador, ensuring a coordinated and informed approach to patient care and engagement.

Although some patients were identified as not having the required monitoring, we found that the practice had effective systems and processes in place to identify such patients and take appropriate action to ensure they were managed safely.

The latest GP Patient Survey carried out, showed that 96% of respondents felt their needs had been met during their last general practice appointment which was above the local average of 88% and the national average of 90%.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The practice was performing below the national target of 80% uptake for cervical screening with the practice having achieved 71.2% for people aged between 25 to 49 years of age. They had achieved 73% target for people aged 50 to 64 years. Childhood immunisation ranges were below in one area with ranges between 89.1% and 93.3%.

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 high levels of deprivation, language barriers and digital exclusion, which impacted patients’ ability to engage with screening and immunisation programmes.

A range of approaches had been implemented to address these barriers and improve engagement. For example, social media campaigns and utilising digital Florey messaging, a mobile-friendly questionnaire sent via SMS or the NHS App, to gather medical information and reduce barriers to participation. This approach generated a further 43 responses. Targeted support was also provided for patients with additional needs, including those with a learning disability, patients on the cancer or palliative care registers, housebound individuals, and those requiring reasonable adjustments.

The practice actively monitored screening outcomes, including attendance rates, routine recalls, and declines. In addition, it delivered awareness initiatives using accessible resources to address common barriers such as fear and misinformation, supporting patients to make informed choices rather than relying solely on recall systems alone.This proactive approach resulted in a 7% increase in breast screening uptake compared to the previous screening round.

The practice demonstrated a strong commitment to improving outcomes through targeted investment in innovative systems and proactive clinical initiatives. This included the use of digital decision support tools, to support earlier identification of cancer and enhance clinical decision making.

In March 2026, the practice transitioned to a new system to support recall monitoring and improve efficiency. At the time of the assessment, this had been implemented alongside a planned dual-running period to ensure continuity of care. The system provided a centralised patient overview for managing long-term condition reviews, drug monitoring, screening, and health promotion. It enabled automated recall processes aligned to clinical need and integrated drug monitoring, ensuring blood tests and reviews were effectively coordinated. Enhanced oversight through real-time visibility allowed staff to engage patients more proactively and reduce delays in care.

The practice had also introduced targeted improvements to support the early detection of conditions. For example, there was a focus on the early identification of non-alcoholic fatty liver disease (NAFLD) in patients with diabetes. Additional targeted screening had been incorporated into annual diabetic review blood test profiles for eligible patients. Where results indicated risk factors or abnormal liver function, patients were offered further assessment. Those identified as being at higher risk were reviewed and managed in line with appropriate clinical pathways, including additional investigations or referral where required.

In addition, the practice proactively offered Prostate-Specific Antigen (PSA) discussions and testing to patients at higher risk, where clinically appropriate. This included patients with a family history of prostate cancer and those from higher-risk ethnic groups. We also observed that the practice displayed targeted literature to raise awareness among these groups. This supported earlier diagnosis and helped to address inequalities in cancer outcomes. For example, of 88 patients invited for PSA testing, 25 chose to proceed, with 5 patients identified as having raised PSA levels and being monitored, and 2 patients diagnosed with prostate cancer, enabling earlier intervention.

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 HRT - appropriate prescribing of systemic oestrogen, audits for the follow up of patients post exacerbation of Asthma, Medical Records clinical consultations audit, Gabapentin and Pregabalin audits, High Dose Vitamin D audit, chronic kidney disease audits and psychotropic medications for learning disability patients.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people 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.