Bevan Medical Group Surgery

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, 99% of respondents said they felt their needs were met during their last practice appointment, compared to the national average of 90%.

The service had systems in place to identify and code carers on the clinical system. As part of routine practice, more than 50 carers were referred to Durham County Carers Support, enabling them to access free or discounted respite activity vouchers for both the carer and the cared‑for person, as well as free role‑specific training courses.
Carers were also supported through signposting to local partner organisations, which provided assistance such as white goods and essential household items.

The practice used social prescribing as part of its approach to assessing patients’ wider needs. The Social Prescribing Link Worker 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 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.

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. An audit reviewing antibiotic prescribing for sore throats found that 29.7% of patients had a documented assessment (using nationally recommended scoring tools) and antibiotics were prescribed in 59.5% of cases. Following actions including staff training, clinical room posters and an electronic prompt, documentation improved to 59.2% and antibiotic prescribing reduced to 44.9% in the second cycle.

A second full-cycle audit reviewed the safe prescribing of Hormone Replacement Therapy (HRT) for women with a uterus. In the first cycle, involving 33 patients, 1 patient was identified as receiving oestrogen‑only HRT and their treatment was corrected immediately. A re‑audit approximately 6 months later, reviewing 13 patients, demonstrated full compliance with national guidance, with no patients receiving oestrogen‑only therapy. The practice had since implemented a prescribing alert to support sustained safe practice.

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 also worked collaboratively with a range of community services, including the frailty team, 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. Staff supported national priorities and initiatives to improve population health.

The practice participated in the Primary Care Network (PCN) frailty service, which provided holistic Comprehensive Geriatric Assessments for severely frail, housebound people. Assessments were planned around what mattered to individuals and delivered at home or remotely by a multidisciplinary team. Recent PCN searches identified 16 people with severe frailty, of whom 3 were not eligible, and the frailty team had begun contacting the remaining patients to offer assessments.

Social prescribing was a core part of the practice’s approach to supporting people to live healthier lives. Since 2022, 841 patients had been referred for holistic, person‑centred social prescribing assessments. For a practice with approximately 8,700 registered patients, this represents around 10% of their population over the period from 2022 to 2026. Many individuals presented with significant challenges, including addiction, homelessness, trauma, domestic abuse, financial crisis, caring responsibilities and social isolation. Through personalised support, people were connected with housing and homelessness prevention teams, recovery and mental health services, welfare and debt advice, carer and veteran support, and community wellbeing activities. Case summaries showed people moving into safe accommodation, receiving crisis financial support, accessing respite and emotional support, and feeling more able to manage their health.

The practice also supported healthier lifestyle choices through targeted smoking cessation work, reflecting high local COPD and asthma prevalence linked to the area’s ex‑mining heritage. People were offered direct cessation support and signposted to specialist services and community programmes.

The service showed a strong focus on empowering people to manage their own health and wellbeing. Staff demonstrated a clear understanding of people’s needs, preferences and abilities, and used this to support people to remain as independent as possible. There was exceptional collaboration across staff, services and community organisations, including through the PCN frailty MDT and extensive social prescribing work. These partnerships enabled people and their families to manage their health effectively at home and, where possible, reduce their future need for care and support.

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.

Verified NHS Digital data for 2024 showed cervical screening coverage was 75.2% for women aged 25–49 and 76.0% for those aged 50–64, both below the 80% national target. However, unverified Quality and Outcomes Framework (QOF) data from March 2025 showed figures of 81.1% for women aged 25–49 and 84.7% for women aged 50–64.

Monitoring by the UK Health Security Agency for 1 April 2024 to 31 March 2025 showed the practice met the 95% WHO target for most childhood immunisations. Uptake for the MMR first dose at age 2 was 94.0%, and the MMR second dose at age 5 was 94.4%. Although slightly below the WHO optimum target, both remained above the national minimum standard of 90%.

To improve vaccination uptake, the practice participated in the Deep End Immunisation Incentive programme, targeting families facing barriers such as non‑attendance, hesitancy and frequent moves. From March 2025, 46 individuals were identified as potentially requiring immunisations; 14 parents declined and 6 children (13%) were vaccinated following targeted follow‑up. This work helped the practice identify outstanding vaccinations and prioritise families experiencing the greatest barriers.

The practice also took part in the Deep End CAREDEEP Cancer Care Coordinator Pilot. Between November 2024 and June 2025, the coordinator engaged patients who had not previously responded to screening invitations. During the pilot, screening uptake increased by 15% for bowel cancer and 4% for cervical screening.

The practice worked with the community‑based diabetes service in collaboration with North Tees and Hartlepool NHS Foundation Trust. The hospital’s Specialist Diabetes Nurse provided 2 clinics per month, seeing around 6–8 patients and supporting the practice’s diabetes nurses with more complex cases. The Diabetes Consultant attended quarterly for face‑to‑face reviews and case‑based discussions. Treatment initiation within the community reduced the need for hospital‑led intervention.

Data showed strong diabetes outcomes across the wider system. County Durham and Darlington Foundation Trust recorded 10 major diabetes‑related amputations over 36 months, among the lowest nationally. The above‑ or through‑knee to below‑knee amputation ratio was 0.25, compared with the national median of 0.58. For diabetic emergencies, the mean length of stay for diabetic ketoacidosis (DKA) admissions was 3.2 days, below the national median of 4.3 days. These outcomes were in line with what we would expect to see in areas where proactive community diabetes clinics operated, as improved monitoring and earlier intervention could support better system‑wide results.

The practice also monitored outcomes for insulin‑dependent, housebound patients who required enhanced glucose monitoring. There were 18 housebound patients with insulin‑dependent diabetes, of whom 10 had been provided with continuous glucose monitoring (CGM) devices and 8 were still to be reviewed for suitability. This enabled safer monitoring and more proactive intervention for people at higher risk of complications.

The practice actively engaged in a range of activities to monitor and improve quality and outcomes, including targeted screening and immunisation work and collaboration across the wider system. Outcome data showed consistently positive performance, with improvements in screening and strong diabetes results across the community pathway.

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. However, in the 3 cases reviewed, 1 patient did not have a scanned DNACPR form available on their record, and therefore assurance could not be obtained that the decision was documented in line with best practice. The practice explained that the patient, who lived in a care home, had a DNACPR completed during a hospital admission, but it had not yet been uploaded to the clinical record.