GP Surgery Care Taking: A Case Study
The Practice Group is an Independent sector NHS provider contracting with the NHS in 41 GP practices and 3 walk in centres. We are responsible for over 200,000 registered patients. Many of our practices are smaller than the English average; in difficult to recruit urban areas and 20% of our patients are from the 10% most deprived areas of the country. We operate PMS/GMS and APMS contracts and across England in a largely dispersed network. The majority of practices joining our group have faced previously challenging circumstances and often require a high degree of turnaround.
The Practice Group’s scale and structure allows for surgeries that require caretaking to be easily brought into our network of Primary Care. Our primary concern when mobilising surgeries that require caretaking is ensuring support and continuity for patients and staff members; realising that this transitional time can be very unnerving for these key stakeholders. Our dedicated mobilisation and operational support teams provide the guidance and vision to these practices to improve services and stabilise the surgery.
What we do
At a time when primary care services are facing challenges with staffing, funding and meeting demand, it is no mean feat to take a surgery or service which is struggling to meet standards and drastically improve the quality of care it delivers.
The Care Quality Commission (CQC) – England’s independent regulator of health and social care – rate GP practices in individual areas such as safety, care and responsiveness using four rating levels. The lowest rating is ‘inadequate’, which means the service is performing poorly and standards are not being met, and therefore requires another inspection within six months to ensure improvements have been made. The next rating is ‘requires improvement’, followed by ‘good’ and ‘outstanding’.
When surgeries are rated ‘inadequate’ or ‘requires improvement’ changes must be quickly made to avoid closures.
Leadership and governance
In 2016 a GP surgery in Hertfordshire, led by two GP partners, received an overall rating of ‘inadequate’ from the CQC. With approximately 5,500 patients on its books, the surgery had been struggling to recruit any permanent doctors and had been forced to reduce the number of nurses and administrative staff, relying on locum GPs to support the service. In the report, the surgery was found to be lacking the systems and processes to ensure clinical leadership and strong governance.
Shortly after the team running the surgery stepped down, and following a failed procurement process, TPG was approached by NHS England to discuss the possibility of taking over the management of the surgery from January 2017. TPG’s patient-centric values and desire to improve local surgeries through their approach of combining local care with centralised support meant that they were able to step in and begin to improve the safety and quality of the service.
Review, review, review
TPG’s operational and clinical teams reviewed the surgery data to create an action plan for improvement in the surgery and after a swift two-week mobilisation – which took place over the festive period, TPG’s service went live on January 2, 2017.
TPG employed an additional four sessional GPs and a practice nurse to join the existing surgery team. By increasing the team members they were able to increase the number of appointments for the patients, as well as bringing some much-needed stability to the surgery team and continuity of care for patients. To add a further layer of governance to the surgery, TPG employed a clinical lead to conduct regular clinical meetings on site and provide leadership and support for all clinicians working within the surgery.
Having reviewed the CQC report and conducting their own risk assessment in the surgery, TPG found that there were some good initiatives and work being done within the surgery but more work was needed to further support the different population groups at the surgery.
One category flagged by the CQC as an area for concern; was the system for checking the monitoring of high-risk medicines, which was not evident upon inspection. Electronic patient records showed that some patients had not received appropriate blood monitoring, and the surgery was instructed to establish a clear process for this so that patients taking high-risk medicines received this vital aspect of care. To improve this aspect of the service, TPG implemented a new standard operating procedure (SOP) and employee training to the surgery, which has worked within other TPG surgeries to ensure appropriate blood monitoring takes place. TPG also implemented a rolling programme of audits of patients who are prescribed high-risk medicines, led by the clinical lead.
Specific surgery policies
Another cause for concern was the surgery’s policies – although these were accessible to staff, the policies in place were not practice-specific in crucial areas such as safeguarding. Making sure employees were informed of a surgery’s policies and that they were specific to the needs of the surgery and patients was of utmost importance to TPG.
As TPG has a centralised support centre with a number of departments dedicated to support their GP surgeries, their quality assurance team stepped in to embed TPG’s wider policies and localising SOPs within the surgery. They ensured correct training and procedures were in place to help prevent and manage incidents. Safety policies including child and adult safeguarding were reviewed regularly and the appropriate training (which includes refresher courses) were made more accessible to staff.
A patient-centered practice
TPG believe that a patient’s involvement in the decisions made about their care is hugely important to their wellbeing. That’s why they developed an active patient participation group (PPG) who they engage with to obtain thoughts and concerns that patients have about the care they receive. This not only enabled TPG to make improvements but gives patients an open forum to share their thoughts.
From special measures to good
The latest CQC report (conducted in March 2018) saw the surgery taken out of special measures and awarded with a ‘good’ rating across all areas including leadership, safety and care. This shows the vast improvements that have been made to provide effective safety measures and leadership initiatives within the surgery.
The surgery and the patients faced some real challenges. What was needed, was a strong, dedicated team and more refined protocols to ensure the day-to-day operations of the practice run smoothly.
Patients’ satisfaction with the quality of care they receive is of huge priority to TPG, and they continue to make improvements, not only here but in their other surgeries across the country, to make sure patients are receiving high quality, safe and responsive primary care.