Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mill Stream Surgery on 10 October 2016. Overall the practice is rated as outstanding. Our key findings were as follows:

• The culture and leadership within the practice provided an open learning environment where all staff contributed to making ongoing improvements to patient care.
• The system in place for reporting and recording significant events enabled positive change and learning to be circulated to staff. Changes were implemented to improve safety and quality. Reviews of complaints, incidents and other learning events were thorough.
• Risks to patients were assessed and well managed. Risks were identified both internally and from external incidents and guidance. This led to clinical and non-clinical protocols resulting to reduce risks to patients.
• Staff assessed patients’ ongoing needs and when they delivered care to patients it was in line with current evidence based guidance. The practice was highly proactive in responding to changes in national guidance.
• The practice was performing well in national data in terms of clinical outcomes.
• Audit was used to further improve care outcomes for patients, even where performance was already high compared to national and local averages.
• The practice planned its services based on the needs and demographic of its patient population. The planning of services was dynamic, allowing changes to services even where feedback from patients was higher than average.
• Screening rates for diseases such as cancer were higher than averages.
• Vaccination rates for children were higher than averages.
• There were well developed processes to ensure the continuity of care, particularly for patients with the most complex health needs.
• Staff were trained in order to provide them with the skills, knowledge and experience to deliver effective care and treatment. The partners ensured a learning environment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patient feedback regarding the approach of staff and care they received was consistently higher than local and national averages.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.
• There was an ethos of continuous learning and improvement.

We identified the following areas of outstanding practice:

• The practice was a high performer in providing screening programmes for specific conditions. The chlamydia screening uptake was 12.7% in the last year, the highest performance among the local group of practices. Of those eligible 62% had undertaken bowel cancer screening compared to the national average of 59% and 82% of had attended breast cancer screening compared to the national average of 73%. The practice’s uptake for the cervical screening programme was 92%, which was significantly higher than the national average of 82%. All patients who did not respond to invitations for reviews were written to and if this did not lead to a response a variety of other means were used such as text reminders or calls to patients’ landlines, for example.
• The practice innovated its own assessment protocols. The local clinical commissioning group adopted some of these including a protocol for headaches developed by the practice. The partners had responded to concerns regarding the diagnosis and complications regarding sepsis nationally in recent months designing a sepsis protocol to assist GPs and nurses.
• To monitor the long term outcomes for patients who previously had cancer diagnoses a comprehensive list of all patients who had historical diagnoses was created. This enabled reference to any patient’s previous diagnosis and resulting treatment and this could be considered in relation to any current illnesses.
• A broad programme of continuous clinical and internal audit was ongoing within the practice even where care outcomes already showed high quality care. Although performance was high for respiratory disorders according national and internal data, the practice repeated yearly audits which showed improved outcomes in line with national guidance. Nurses undertook their own audit.
• The practice continued to review and improve areas of its service even where patient feedback suggested high performance. For example, the practice undertook a review of its appointment system in early October 2016 as part of its away day to identify where any further improvements could be made. This led to short, long and medium term actions to improve the appointment system. For example, the means by which patients were contacted for follow up appointments, and longer term, whether extended hours appointments needed reviewing. This was despite 100% of patients finding it easy to contact the surgery by phone in July 2016 compared to the CCG average of 84% and 91% patients describing their experience of making an appointment as good compared to the CCG average of 80%.
• Efficiencies which led to savings within the practice were re-invested in services. For example, prescribing incentive funds were used to fund a cognitive behavioural therapy (CBT) service in-house.
• The patient panel (a patient reference group) very involved in the core decision making of the practice. For example, panel members undertook their own independent interviews of prospective GPs during recruitment and then took part in the determination of appointment following the partners’ interviews.

Areas the provide should make improvements are:

• Consider purchasing a hearing loop
• Review the carers’ register to identify any carers not listed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice