Lister House Surgery - Luton

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

We looked for evidence that the practice met people’s needs, and that staff treated people equally and without discrimination.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected patients' physical, mental, emotional and social needs, including any needs relating to protected characteristics under the Equality Act. Our review of clinical records demonstrated that patients were supported to understand their conditions and were actively involved in decisions about their care, treatment and ongoing support. Records showed that care planning was personalised and developed in partnership with patients, ensuring their individual needs, preferences and circumstances were considered.

National GP Patient Survey results from July 2026 indicated performance below local and national averages across several patient experience measures, including access, communication, involvement in decisions about care and treatment, and confidence and trust in healthcare professionals. Fewer patients than average reported feeling listened to, involved in decisions about their care and being, or treated with care and concern. Practice leaders were aware of these findings and recognised the need to continue improving patient experience, communication and engagement.

Despite these results, evidence gathered during the assessment demonstrated a commitment to delivering person-centred care. Staff described taking a holistic approach to assessing and managing patients' needs, taking account of their health conditions, personal circumstances and goals. Clinical records showed that care and treatment plans were personalised and reflected patients' views, preferences and priorities, helping to ensure people were involved in decisions about their ongoing care and support.

The practice served a diverse population and had systems in place to meet patients' communication and accessibility needs. Staff routinely recorded information relating to language, communication and reasonable adjustment requirements and arranged interpreting services, sign language support and other assistance when required. The practice also provided alternative access routes for patients who were unable or less confident using digital services, helping to reduce barriers and support equitable access to care.

Preventive healthcare was delivered in a personalised manner. Staff described contacting patients who did not attend screening appointments, health reviews or monitoring appointments to discuss any concerns, provide information and encourage engagement with services. This helped patients make informed choices about their care and treatment.

While patient survey results highlighted opportunities to improve communication and patient experience, evidence reviewed and discussions with staff demonstrated that staff worked to place patients at the centre of care planning and decision-making. The practice recognised the areas requiring improvement and was taking steps to strengthen patient engagement and shared decision-making while continuing to deliver care tailored to patients' individual needs and preferences.

The practice understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The practice worked with a range of healthcare providers and community services to ensure patients could access the most appropriate support for their needs. Leaders demonstrated a good understanding of the needs of the local population and supported access to a wide range of services. Patients could be referred, or self-refer where appropriate, to services including physiotherapy, wellbeing support, sexual health services and Pharmacy First. Staff also signposted patients to community services and social prescribing support where non-clinical interventions may improve health and wellbeing. This helped ensure patients received timely care from the most appropriate healthcare professional or service.

Regular multidisciplinary team (MDT) meetings and weekly care home review meetings supported the planning and delivery of care for patients with complex health and social care needs. Care planning involved GPs, care home staff and other healthcare professionals, enabling information to be shared effectively and ensuring patients received coordinated and timely support. These arrangements helped maintain continuity of care, reduce duplication and support early intervention when concerns were identified.

The practice had systems in place to support continuity of care wherever possible. Patients could request to see their preferred GP, particularly for ongoing or complex issues, although availability could affect waiting times. Staff told us they recognised the benefits of continuity and aimed to ensure that patients with long-term conditions, complex health needs or significant life events received consistent support from clinicians familiar with their circumstances.

Feedback from the care home was positive regarding the coordination of care provided by the practice. Staff reported that communication with the surgery was consistently good and that queries were responded to promptly. They told us they were able to contact the practice when support was required and that planned GP visits took place reliably. Residents received regular reviews, medication monitoring and ongoing assessment of their healthcare needs. The care home described the practice as accessible, responsive and supportive, helping to ensure residents received appropriate medical care and continuity of support.

The practice supplied 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 practice met the Accessible Information Standard. Patients were informed as to how to access their care records.

The practice took a proactive approach to providing patients with clear, relevant and timely information to support their health, wellbeing and involvement in care decisions. Information was available through a range of channels, including face-to-face discussions, telephone contact, printed materials, text messaging and digital communications, helping to meet the diverse needs of the practice population.

Patients were routinely provided with information about available services, health promotion activities, screening programmes, vaccinations and long-term condition management. The practice used recall systems, text messaging campaigns and Accurx communications to share important health information, encourage engagement with services and support participation in preventative healthcare programmes. Information relating to NHS Health Checks, smoking cessation services, weight management programmes, diabetes prevention and national screening initiatives was regularly promoted.

The practice recognised that patients had different communication and accessibility needs. These needs were recorded within patient records, enabling staff to arrange interpreter services, sign language support and other reasonable adjustments where required. Staff were also able to provide additional support for patients who experienced difficulties using online systems, ensuring they could access information and services through alternative methods where necessary.

Health promotion information was readily available throughout the practice through noticeboards, posters, leaflets and digital information screens. Staff also signposted patients to community services, social prescribing resources and local wellbeing programmes, helping them access wider sources of advice and support relevant to their individual circumstances.

Staff described taking time during consultations to explain diagnoses, treatment options, medicines and follow-up arrangements, enabling patients to better understand their health conditions and make informed decisions about their care. Information was adapted where necessary to meet individual communication, language and accessibility needs.

The practice demonstrated a commitment to ensuring information provided to patients was accurate, accessible and up to date. Following inspection feedback, information displayed within the waiting area was reviewed and updated to improve clarity, consistency and accessibility for patients.

Evidence showed that patients were provided with accessible and appropriate information that supported them to understand their health, access services and make informed decisions about their care and treatment. This helped promote patient involvement and supported people to take an active role in managing their health and wellbeing.

The practice made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The practice had systems in place to gather, review and respond to patient feedback, using complaints, compliments and patient engagement activities to identify learning and support service improvement. A complaints policy and complaints register were maintained, and concerns were investigated in line with established procedures. We found evidence that complaints were responded to in a timely manner and that outcomes were communicated appropriately to complainants.

Common themes in complaints included communication, access to appointments, prescribing queries, continuity of care and administrative processes. Although investigations often concluded that clinical care and decision-making had been appropriate, complaints highlighted opportunities to improve communication, provide clearer information to patients and strengthen administrative processes which were acted on.

Learning from complaints was shared across the practice through governance meetings, team meetings and staff discussions.

The practice worked with its Patient Participation Group (PPG) to understand patient views and support service development. The PPG representative described a positive and constructive relationship with practice leaders and told us the practice was receptive to feedback and willing to make changes in response to patient concerns. They provided examples of how patient feedback had informed improvements to access arrangements, including the review and refinement of the practice's online appointment and access system following concerns raised by some patients. The representative told us the practice listened to feedback, engaged with patients throughout the process and implemented changes which improved the user experience and accessibility of the system.

Evidence demonstrated that leaders used patient views and experiences to support continuous improvement and improve the quality of care provided.

The practice reviewed access and demand data to identify opportunities to improve how patients accessed services and to reduce barriers for groups who may experience health inequalities. Leaders demonstrated an understanding of the needs of different patient groups, including older people, patients with disabilities, people whose first language was not English, vulnerable patients and those less confident using digital technology.

Following a review of access arrangements, leaders identified that some patients experienced difficulties navigating the Total Triage model and online access routes. In response, staff were trained to provide support both by telephone and in person to help patients submit triage requests and access appointments. Staff described how they routinely supported patients who were unable to use digital systems independently, helping to ensure access to care was not solely dependent on digital literacy. Feedback from the Patient Participation Group (PPG) reflected positively on these arrangements.

The practice premises were accessible and included step-free access, disabled facilities and ground-floor consultation rooms to support patients with mobility needs.

Leaders routinely reviewed patient feedback, appointment utilisation and access data to understand patient experience and identify areas for improvement. However, patient feedback and performance data demonstrated that challenges remained. The National GP Patient Survey results published in July 2026 were below local and national averages across a number of access indicators. Only 32% of respondents reported it was easy to get through to the practice by telephone, compared with the average of 52% locally and 57% nationally. In addition, 39% of respondents found it easy to contact the practice using the website, compared with 60% across the local average and 58% nationally. Similarly, 31% of respondents found it easy to contact the practice using the NHS App, compared with 52% across the local average and 54% nationally. These results indicated that patients experienced difficulties accessing the practice through digital channels as well as by telephone.

These findings indicated that patients continued to experience difficulties accessing the practice through a range of communication channels despite actions taken to improve access.

The practice also used population health data to identify potential inequalities in access to preventative care. Cervical screening uptake for women aged 50 to 64 years was in line with national targets; however, uptake among women aged 25 to 49 years remained below expected levels. Childhood immunisation uptake was also below recommended thresholds for several indicators, including MMR and booster vaccinations. While leaders were aware of these concerns and had plans in place to increase engagement and uptake, performance remained below expected levels.

To address identified issues, leaders had introduced a range of measures, including enhanced care navigation, increased use of the multidisciplinary team, extended access appointments and ongoing monitoring of demand and capacity. These arrangements demonstrated a proactive approach to improving access and ensuring patients were directed to the most appropriate service. However, evidence from patient survey results and preventative health indicators suggested that these actions had not yet resulted in consistently positive outcomes for all patient groups.

Feedback from the PPG was generally positive regarding the practice's engagement and willingness to adapt services. Representatives acknowledged that the practice had listened to concerns about digital access and had maintained alternative methods of contact for patients who preferred telephone or face-to-face interactions. However, they also recognised that some patients, particularly older patients, continued to experience challenges accessing services.

Overall, the practice demonstrated an awareness of potential barriers to access and had implemented appropriate measures to support patients and reduce health inequalities. However, patient experience data and preventative care outcomes indicated that further improvement was required to ensure patients could consistently access services in a timely way and achieve equitable health outcomes. As a result, although leaders had taken reasonable action to address concerns, the impact of these actions was not yet fully evidenced in performance or patient feedback.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The practice demonstrated a good understanding of the factors that can contribute to inequalities in patient experience and health outcomes and had implemented a range of measures to identify, support and improve outcomes for patients who may be at greater risk of disadvantage. Leaders recognised the impact that language barriers, digital exclusion, age, disability, social circumstances and long-term health conditions can have on access to healthcare and worked proactively to address these challenges.

Feedback from patients was generally positive, with patients reporting that they were treated fairly, respectfully and without discrimination. Staff understood the importance of providing inclusive care and were able to describe how they adapted services to meet individual needs. Patients requiring additional support were identified through clinical systems and offered reasonable adjustments, including interpreter services, longer appointments, assisted access to digital services and personalised follow-up where appropriate.

The practice had arrangements in place to identify and support patients who may be at greater risk of poorer health outcomes. Clinical systems were used to recall patients for long-term condition reviews, medication monitoring, vaccinations and screening programmes. Staff took additional steps to contact patients who did not initially respond to invitations, helping to reduce the risk of individuals missing important care and treatment.

The practice supported vulnerable patients and those experiencing barriers to healthcare. Registration processes were flexible and ensured services remained accessible to people in vulnerable circumstances. Staff were aware of the needs of patients who may experience health inequalities and worked to ensure these patients could access appropriate care, support and follow-up.

Leaders had reviewed the impact of the Total Triage system and recognised that some patients, particularly older people and those who were digitally excluded, found the process more challenging. In response, trained staff provided support by telephone and in person to help patients navigate the system and access care. This helped reduce inequalities associated with digital exclusion and ensured patients could continue to access services in a way that met their individual needs.

The practice recognised that social, economic and environmental factors could affect patients' health outcomes and worked with Primary Care Network (PCN) and community services to help address these inequalities. Patients could access social prescribing services for support with issues such as social isolation, housing concerns, financial difficulties and community engagement. The practice also utilised PCN services, including clinical pharmacists, to support medicines optimisation, long-term condition management and diabetes care. Through targeted recalls, personalised support, reasonable adjustments and referral to wellbeing initiatives and community-based programmes, the practice took steps to reduce barriers to care, improve engagement and promote more equitable health outcomes for its patient population.

The practice did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. 

The practice had most systems in place to support future care planning for patients with frailty, complex needs and long-term conditions. Staff collaborated with patients, carers, care homes and community services to discuss future care needs and used ReSPECT documentation where appropriate to support treatment and care planning.

The practice undertook regular reviews of vulnerable patients and used clinical searches, recall systems and monitoring processes to identify patients who may be at risk of deterioration. Patients also had access to wider Primary Care Network services, including clinical pharmacists, social prescribers and mental health practitioners, which supported coordinated care planning.

However, we identified improvements were required in the management and accessibility of some Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation. Although DNACPR decisions had generally been made appropriately and involved relevant discussions, copies of signed DNACPR forms were not always available within patient records, particularly where decisions had been made by external healthcare providers before registration with the practice. This created a risk that valuable information may not be readily accessible when needed.

Following our findings, the practice reviewed affected records and introduced a formal process to ensure DNACPR and ReSPECT documentation is requested, reviewed and uploaded when patients transfer from hospitals, care homes, hospices or other healthcare providers.

While the practice demonstrated a proactive approach to future care planning, improvements were required to ensure future care decisions were consistently documented and readily accessible within patient records. The practice recognised this and had taken action to strengthen its processes.