Saville Medical Group

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 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 good. At this assessment, the rating remains the same.

This service scored 79 (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.

Feedback from people using the service was positive; in the 2025 GP Patient Survey, 95% of respondents said they felt their needs were met during their last practice appointment, compared to the national average of 90%.

Our review of the clinical searches indicated that the practice actively identified and addressed patient needs in relation to long-term condition management. No significant concerns were found. For example, 33 patients (3.8%) with hypothyroidism were overdue thyroid function tests; however, all had been recalled for follow-up.

The service had systems in place to identify and code carers on the clinical system. The practice worked in partnership with Newcastle Carers to support carers’ health and wellbeing. In June 2025, Newcastle Carers delivered training at a GP educational meeting to raise awareness of carer health needs and the support services available.

Following further meetings, agreed actions included regular sharing (with consent) of carer information from Newcastle Carers to ensure the Carers Register was kept up to date, ensuring more carers were identified and supported. As a result, 155 carers consented through Newcastle Carers to share their details. When patients were added to the register, the practice sent text messages offering support and signposting to relevant services.

Newcastle Carers also provided direct access to advice through planned drop-in sessions held at the practice sites. These sessions were aligned with learning disability and dementia clinics to improve accessibility. Information about the drop-in sessions was shared via social media and text messages were sent to carers on the register. Sessions took place on Thursday 20 November at Newbiggin Hall and Thursday 4 December at Saville Place. All 446 carers on the register were invited to attend through text messages, supported by posters in waiting rooms and staff signposting. Five carers attended the first session, including 1 who also attended a learning disability and dementia review clinic, and none attended the second session. Leaders told us a meeting was planned with Newcastle Carers in January 2026 to discuss further collaborative working, including an approach called “consent to contact,” which would allow Newcastle Carers to contact carers directly rather than relying on self-referral.

The practice used social prescribing as part of its approach to assessing patients’ wider needs. Social Prescribing Link Workers undertook holistic conversations to identify social, emotional, and lifestyle factors affecting health, including housing, financial hardship, mental health, social isolation, and long-term wellbeing. This enabled patients to be matched to appropriate community and specialist support based on individual need.

Reception staff used digital flags within the clinical system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator, tailoring communication and care to individual requirements.

This demonstrated that the practice ensured there was a consistent and person-centred approach to assessing and reviewing people’s health, wellbeing and communication needs, with adjustments made in partnership with individuals to support effective access to care.

The service planned and delivered people’s care and treatment in partnership with them, taking into account what mattered to them. Care was provided in line with legislation and current evidence-based guidance and standards.

The practice had completed full-cycle clinical audits to support quality improvement. One audit reviewed compliance with post-asthma exacerbation reviews within 2 working days as recommended by NICE (National Institute for Health and Care Excellence) guidelines. This timeframe is advised because patients are at higher risk of another asthma attack soon after an exacerbation, and early review helps check treatment, adjust medication, and prevent further episodes. In April 2025, only 5% of patients were reviewed within this timeframe and 82% received no review. Following education and agreed changes, re-audit in November 2025 showed improvement, with 17% reviewed within 2 days and those receiving no review reducing to 40%.

Another audit assessed the safety of spironolactone prescribing for women with polycystic ovary syndrome (PCOS) against national and international guidelines. Spironolactone is used off-licence to help reduce symptoms such as unwanted hair growth (hirsutism) and severe acne. The initial audit in November 2024 demonstrated generally safe prescribing but identified gaps in blood pressure monitoring and structured follow-up. Following shared learning and system changes, re-audit in November 2025 showed improved compliance, including 100% completion of baseline blood pressure and blood test checks, alongside better documentation of follow-up and safety advice.

A further audit reviewed opioid prescribing against national guidance and demonstrated a reduction in prescribing, with an average reduction of 38.6mg in oral morphine equivalent dose per patient following structured medication reviews.

In addition to completed 2-cycle audits, the practice routinely undertook single-cycle audits aligned with national guidance to identify risks and inform service improvement. Systems were in place to ensure staff were kept up to date with evidence-based guidance and legislation, and clinical records reviewed confirmed care was provided in line with current guidance.

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

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.

Multidisciplinary team (MDT) meetings supported joined up working across the practice and wider community services. The practice was linked to 4 care homes, each with a named GP who carried out weekly visits. GPs rotated every 4 months to ensure shared knowledge of residents while maintaining continuity. The care home team met formally each month to review processes and discuss complex cases and held weekly pre-visit “huddles” to review patient lists and coordinate cross-cover where needed.

The practice also worked collaboratively with a range of community services, including specialist care home support teams, the geriatric MDT, community nursing teams, and specialist services such as community diabetes and palliative care teams, to ensure coordinated, person-centred care.

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

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.

The service prioritised carers’ health and wellbeing by proactively identifying carers and offering tailored support. This included signposting to specialist advice and local networks, and hosting drop-in sessions in partnership with Newcastle Carers. These sessions were aligned with dementia and learning disability clinics to make support more accessible, helping carers maintain their own health while continuing in their caring role.

The practice supported the early identification of liver disease by implementing a screening programme for patients at increased risk. Using targeted clinical system searches, eligible patients were proactively identified and offered diagnostic assessment within primary care.

Between May and December, 554 patients were scanned. Of these, 48 patients (9%) were identified with liver fibrosis, including 14 patients with advanced fibrosis or cirrhosis, enabling earlier diagnosis, monitoring and intervention than would otherwise have occurred.

All patients received lifestyle advice at the time of assessment, supporting prevention and risk-reduction. High patient engagement was demonstrated, with 92% reporting satisfaction and 90% stating the GP-based setting was more convenient, supporting effective uptake of the intervention.

This approach demonstrated the effective use of validated diagnostics to improve early detection and clinical outcomes for patients at risk of long-term liver disease.

Social Prescribing Link Workers were embedded within the practice and wider Primary Care Network (PCN) team, with specialist expertise in areas including smoking cessation, weight management, alcohol support, mental health, and social isolation.

During 2024 and early 2025, the service supported a total of 637 referrals, with activity continuing to increase to 706 new referrals more recently. Referral activity to social prescribers was significantly higher compared to another PCN in the same locality, based on unverified data.

Patients were supported to access onward services for housing, financial hardship, mental health, carer support, and community-based exercise and wellbeing.

The impact of social prescribing was evidenced through patient feedback forms and anonymised case studies. Twelve patient feedback responses were received, all of which reported that patients felt supported and listened to.Most patients reported an improvement in wellbeing following intervention.Two anonymised case studies showedclear change following support: patients who had not previously accessed support wereenabled to engage with appropriate services, resulting inimprovements in sleep, mood, sense of hopefulness, feelings of safety, and ongoing engagement with support services.

The practice also promoted preventative health through routine health checks and monitoring, including NHS Health Checks and blood pressure reviews. Patients had access to self-monitoring equipment, including a blood pressure monitor and weighing scales located in the reception area, encouraging patients to take an active role in managing their health. Pop-up alerts within the clinical system prompted staff when patients were due checks, and non-attenders were followed up to encourage engagement.These systems supported early identification of risk factors and helped patients make informed choices about their health and wellbeing.

The service 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.

In 2024, verified data from NHS Digital’s Cervical Screening Programme showed that cervical screening coverage was 36.2%for eligible women aged 25 to 49 and 71.2%for those aged 50 to 64, both below the national target of 80%. The practice recognised this as a key area for improvement, particularly given the challenges associated with local population demographics.

The practice told us they implemented a range of targeted measures to improve uptake, including proactive text message reminders, offering flexible appointment times including morning and evening slots, dedicated “Smear Saturday” clinics, and online booking options. Leaders also told us they undertook quality improvement activity to improve inclusivity by supporting access for trans men and other eligible patients and worked with a community health bus service to help reach patients who found it difficult to attend the practice.

Monitoring of more recent performance data showed a positive impact from these actions. Unverified Quality and Outcomes Framework (QOF) data from November 2025 indicated that screening coverage had increased to 62%for women aged 25 to 49 and 85%for those aged 50 to 64. This demonstrated that the practice had effectively used data to monitor performance, implement improvement, and achieve better outcomes for patients.

Monitoring by the UK Health Security Agency for the period 1 April 2023 to 31 March 2024 showed the practice met the 95% World Health Organisation (WHO) targetfor all childhood immunisations except 1. Uptake of the 2-dose measles, mumps and rubella (MMR) vaccine in children aged 5 was 91.6%, which met the national minimum target of 90%, although it remained below the WHO optimum target.

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.