Midlands Medical Partnership

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.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. When a person lacked the capacity to make decisions, those who were significant in their life were actively involved in best interest decision-making as part of a multidisciplinary team.

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.

Reception staff were aware of the needs of the local community. Reception staff used digital alerts 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. Staff checked people’s health, care, and wellbeing needs during health reviews.

Clinical staff used templates devised and adapted by their clinical team, 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. There were 100 (0.2%) patients identified by our clinical searches as having the potential for a missed diagnosis of diabetes. We sampled 5 of the 100 records and found these to be satisfactory with no evidence of a missed diabetes diagnosis.

Our clinical searches found 1.5% of the total number of patients with diabetes (826) and a high blood sugar monitoring result (HbA1c >75mmol/l). We sampled 5 of the records and found these to be satisfactorily monitored and reviewed.

There were 10 patients (0.7%) with hypothyroidism our clinical searches identified as having the potential for not having had thyroid function test monitoring for 18 months. We sampled 5 out of the 10 records. Four of the 5 patients reviewed had follow up recall reminders in September and 1 patient had a best interests document in place regarding blood tests.

There were 3 patients with chronic kidney disease at stage 4 or 5, who had the potential to have not had blood test monitoring in the last 9 months, (1.2%). We reviewed these records and found that 2 of the 3 had been tracked for a review in July/August and the other was only just due a review.

The total number of patients with asthma who had been prescribed 2 or more courses of rescue steroids, was 217 (3.8%). We sampled 5 of the 217 records. Two of the 5 had been reviewed, and 3 had been followed up to remind them to attend.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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 were up to date with evidence-based guidance and legislation. For example, the clinical search records we reviewed for people who received treatment following an exacerbation of their asthma demonstrated they were followed up within 48 hours, recalled if they did not respond and had evidence of safety netting advice. Clinical records we saw demonstrated 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. People had access to additional support and services for example, social prescribers, physiotherapy, and mental health practitioners.

The service held a continuity of care approach ethos, with GPs in general working from 1 or 2 of their sites despite being a larger group of practices to promote patient rapport and trust. The clinical team had contributed to bespoke clinical templates and care plans for individualised support. They had a centralised dedicated pharmacy and medicines management optimisation team. The service provided staff training and development opportunities which included career progression.

There were several examples of collaborative working with external providers for the benefit of patients which included for example, Birmingham Children’s Hospital(BCH) operates specialist asthma clinics for children in collaboration with Midland Medical Partnership. These clinics provide localised care for children with poorly controlled or high-risk asthma. Clinical staff reported that the additional education offered through this initiative was highly beneficial, describing it as invaluable to their professional development and clinical practice.

The service always supported people to manage their health and wellbeing to fully 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. There was a strong focus on empowering people to maximise their opportunity to manage their own health, care and wellbeing needs as much as possible. Staff fully understand people’s needs, preferences, and abilities, which enables them to identify and enable as many opportunities as possible for people to be independent.

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. Eligible people were invited for the NHS health check, to identify any potential health issues.

The service had facilitated an initiative developed by one of the GP partners, called the ‘Wall of FAME,’ (Facilitating Achievement, Motivating Empowerment). This recognized and celebrated individuals who had taken proactive steps to transform their health; shifting their mindset and building adaptive habits. This also aimed to set powerful example for others, by highlighting people’s health improvement stories. The service told us that the launch event had served as an opportunity to introduce the initiative, engage with key stakeholders, and lay the groundwork for future expansion and sustainability. There were 20 participants at the launch event, including GPs, staff members, inducted patients, and their family members. The service inducted staff members to become health champions and formally recognised 6 patients for their personal health improvement achievements, with 3 attending the official launch event. The initiative aimed to foster positive change throughout the community, encouraging individuals to take proactive steps toward improving their health and wellbeing. Post-event feedback indicated exceptionally high satisfaction, with all attendees rating the experience 5 out of 5. Furthermore, 100% of participants stated they would strongly recommend others to join the Wall of FAME initiative, and all expressed a clear interest in remaining engaged and receiving future updates. Following the display of the Wall of FAME there was a noticeable increase in interest from both staff and patients, seeking to become involved. Individuals commented that they felt genuinely valued for making a positive difference in their own lives, an experience they found unexpected, as good health was not typically recognised or celebrated in this way. The diversity of patient storiesdemonstrated various adaptive health habits was a key inspiration. Patients expressed happiness seeing their mindset shifts recognized and celebrated.

For the 2025/26 period, the service developed a quality improvement initiative aimed at addressing health inequalities among individuals with learning disabilities. The initiative focused on enhancing both the uptake and clinical quality of annual health checks, with a particular emphasis on cardiovascular disease prevention. This approach reflects a proactive commitment to reducing disparities and promoting long-term health outcomes for this vulnerable patient group.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

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.

The service demonstrated awareness and had developed strategies and action plans regarding the uptake of childhood immunisations and cervical screening. For example, between 2023 and 2024:

•The percentage of children aged 5 who had received the immunisation for measles, mumps and rubella (two doses of MMR), was 76.9% of the World Health Organisation (WHO), 95.0% target.

•The percentage of children aged 1 who had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b, Hepatitis B was, 89.7% of the WHO target of 95.0%.

•The percentage of children aged 2 who had received their booster immunisation for Pneumococcal infection was 83.8% of the WHO target, 95.0%.

•The percentage of children aged 2 who had received their immunisation for Haemophilus influenza type b and Meningitis C between 2023 and 2024 was 84.7% of the WHO target of, 95.0%.

•The percentage of children aged 2 who had received immunisation for measles, mumps and rubella was 83.8% of the WHO target of, 95.0%.

The provider implemented comprehensive action plans to improve immunisation uptake, including robust call and recall systems. Strategies included, addressing barriers such as hesitancy, access and health awareness, patient education events, personalised letters from the nursing team following their child’s birth, focused campaigns of primary immunisation uptake and locality working.

A dedicated care coordinator was appointed to support, educate, and assist families, with tracking mechanisms in place to identify children overdue for vaccinations and facilitate outreach and follow-up appointments. These processes operated under clinical partner oversight, with escalation protocols for repeated non-engagement and systems to monitor children not brought to appointments. Quarterly reports were shared with safeguarding leads for review.

The service ran dedicated vaccination clinics, supplemented by additional sessions during school holidays. Clinical staff engaged directly with parents who declined attendance, offering educational discussions and one-to-one conversations to address concerns. Care coordinators received enhanced training, including the use of digital tools such as reminder texts and direct booking links to streamline access. Parental information was provided on vaccine options, including gelatine-free alternatives.

In August 2024, the service collaborated with the Integrated Care Board (ICB) immunisation team on a targeted call and recall project. An analysis was conducted to identify trends among children who missed vaccinations. This work resulted in 16 additional children receiving vaccinations. The service reviewed results data within their Integrated Care Boards (ICB) and found a positive variance of between 5.1% and 8.2% in their immunisation uptake rates for children aged 1 and 2 years, when compared to other services.

The service conducted continuous monitoring of screening uptake. As of June 2024, cervical screening uptake among eligible women aged 25 to 49 years was 56.7%, falling short of the national target of 80%. For women aged 50 to 64 years, uptake during the same period was 69.0%, also below the national target. The service had completed action plans to increase uptake of cervical screening which included call and recall systems together with the additional support of a women’s health specialist nurse and patient education.

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.

We randomly sampled a selection of the Recommended Summary Plan for Emergency Care and Treatment form (ReSPECT) forms. We looked at the systems in place to support patients in documenting their preferences supported by family/advocate/carers. A ReSPECT form is a personalised plan created through conversations between the individual, their family, and healthcare professionals, detailing what treatments the person would or would not want in an emergency whenthey may not be able to communicate their wishes. The forms we reviewed demonstrated a patient-centred approach, including reviews following discharge from acute illness in secondary care.

A quality improvement audit was completed by the service on how DNACPR decisions were made in February 2022 and a repeat audit cycle completed in January and August 2024 with positive improvement findings.

Bereavement support included condolence, the offer of face-to-face appointments, signposting to supportive local groups and alerting front line staff of recent bereavements and appropriate electronic coding.