Letter from the Chief Inspector of General Practice

Holsworthy Doctors was inspected on Monday 8 December 2014. This was a comprehensive inspection.

Holsworthy Doctors practice provides primary medical services to people living in a rural areas in North Devon covering approximately 250 square miles. Transport links within the area are limited. Holsworthy Doctors provides the highest level of area coverage within England. The area is mostly rural, with high percentage of agriculture and mid range deprivation. The practice provides primary medical services to a diverse population and supports patients living in eight adult social care homes in the area. Holsworthy community hospital is situated next to the practice and GPs have responsibility for 10 patient beds there. At the time of our inspection there were 10,700 patients registered at the service. The practice had a higher than national average number of patients of working age and older people, with fewer children and young people in the total practice population.

The practice has 7 full time GP partners; three male and four female GP partners. There are two Advanced Nurse Practitioners (female). The GPs are also supported by five practice nurses (female), four health care assistants (female) and two phlebotomists (female). The practice manager is also a partner, the registered manager with CQC and manages a large team of administrative staff. Holsworthy Doctors is a training practice, with two GP partners approved to provide vocational training for GPs, second year post qualification doctors and medical students. When we inspected there was GP and two second year registered doctors completing training placements at the practice.

Patients who use the practice have access to community staff including social workers, district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

The practice is rated as OUTSTANDING.

Our key findings were as follows:

• Patient satisfaction was higher than the national average, 92% compared with 86% in the 2014 GP survey. Fifty nine patients gave feedback at the inspection, in person (34) or in writing (25). All confirmed they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. The practice had a very good skill mix which included two advanced nurse practitioners (ANPs) and was able to see a broader range of patients than the practice nurses.
• The practice was purpose built and very well equipped to treat patients and meet their needs.

We saw several areas of outstanding practice including:

• The practice had a strong vision which had quality and safety as its top priority. A comprehensive business plan was in place, which was monitored and regularly reviewed. Progress with this and action plans were discussed with all staff and shared with PPG members. High standards were promoted and owned by all practice staff with evidence of team working across all roles and with external agencies. The practice held registers for every population group and used tools like the Kings Fund predictive model to rate risk so knew which patients could be at risk of unplanned admissions and ensured appropriate support was in place and well co-ordinated by the community team.

• The practice understood the needs of the patient list and the challenges of the rural location and had developed a responsive service accordingly. There were many examples of this seen at the inspection. The practice hosted specialist clinics at the practice for procedures normally offered at the main hospital (29 miles away) such as diabetic retinal screening (held 3-4 times a year) regular hospital nurse specialist appointments for patients with complex diabetes and leg ulcer treatment. Access for working patients was facilitated through the availability of early morning appointments every day of the week and weekend clinics for flu vaccination were available throughout the Winter months. Patients were able to request repeat prescriptions and appointments online and sms texting was used for appointment reminders and blood test results. The patient list was managed in a way to avoid any barriers, for example patients who moved out of area were able to remain registered with the practice for continuity of care and treatment. Approximately 1482 patient appointments were delivered each month, which far exceeded the 802 expected for the list size. GPs carried out an average of four home visits each per day, travelling up to 15 miles on rural roads to reach patients in need. The practice also provides pre-hospital emergency care to patients until the ambulance or air ambulance service arrives..

• The practice was innovative in promoting collaborative working with other agencies to improve outcomes for patients. Significant challenges were overcome by the practice, which facilitated well co-ordinated safeguarding and management of patients with complex care needs. Social services were able to use the practice facilities for safeguarding strategy meetings, which had further enhanced working relationships. Patients, particularly women experiencing domestic violence were able to access discreet face to face social care support at the practice once a week. Holsworthy Doctors held monthly multidisciplinary meetings, which included hospital specialists from the palliative care team. The practice knew that it was difficult for patients needing palliative care support to travel to the local hospice approximately 25 miles away, so had facilitated the building of a satellite day hospice on land owned by the practice. Data showed 100% of all patients newly discharged from hospital following an emergency admission were contacted within 24 hours by GPs from the practice to ensure they had appropriate care, treatment and support.
• The practice significantly improved access to support for patients living with long term conditions and their carers. For example, the Memory Matters programme run by the Alzheimer's society was hosted at the practice. This enabled carers and patients to attend who would otherwise be unable to travel the distance to Bideford or Barnstaple.

Patient participation was achieved in two ways, through a virtual PPG (50 patients) and face to face meetings with representatives from the Patient Participation Group (PPG). Their suggestions had developed into work streams to implement changes at the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice