We carried out an announced inspection at The University of Nottingham Health Service on 8 February 2019 as part of our inspection programme.

At the last inspection in June 2015 we rated the practice as outstanding overall, specifically in effective, caring and well led.

We based our judgement of the quality of care at this service on a combination of:

• What we found when we inspected

• Information from our ongoing monitoring of data about services and

• Information from the provider, patients, the public and other organisations.

We have rated this practice as outstanding overall.

We rated the practice as outstanding for providing responsive services because:

• The new building allowed the re-introduction of the in-patient unit. This is a room with four hospital beds, used for observing patients who are not well or undergoing treatment. This allowed staff to monitor patients who may otherwise be sent back to their student accommodation without any support and likely be referred to secondary care as a safety net.

• Services were hosted in the building as it was found to increase engagement with patients and increase the attendance of clinics. These include clinical sessions for eating disorders in student services’, midwifery services, physiotherapy, and non-obstetric ultrasounds.

• Practice staff delivered a range of targeted and proactive health promotion. The initial, and main event, being Fresher’s Week’ which runs alongside the registration event. Whilst students are queuing, the time is used to explain the range of services available to them and how to use them in the most appropriate manner. This was a four-day event and the stand was visited by over 8000 people. To utilise this exposure, outside agencies were invited to be part of the stand. They included drugs and alcohol services, ‘Sustrans’ (promoting cycling and sustainable transport), a student lead mental health support organisation, safe sex promotion and the university counselling and mental health advisory services.

• Working closely with the University of Nottingham Student Union, practice staff took part in a number of health promotion roadshows which visited halls of residence and student union buildings. During these visits’ students were offered sexual health screening and signposted to further support where appropriate.

• Specialist events were also supported by staff, this included:

▪ Lectures to medical students and junior doctors on sports medicine and life as a GP’

▪ Introductory talks for newly arrived international staff on registering and using the NHS appropriately.

▪ Talks on men’s heath during ‘Movember’ entitled ‘Meat and two veg’ which was widely promoted

across the university.

• The practice was the first University Health centre to be certified as a ‘parkrun’ practice. This initiative, by parkrun UK in partnership with the Royal Collage of General Practitioners aims to prescribe an active lifestyle to patients and practice staff. The aim is increased awareness amongst all practice staff, of parkrun and the positive impact physical activity and volunteering can have on health and wellbeing.

• Specialist clinics were organised on differing days throughout the year to ensure students with a regular timetable were able to find a convenient time for their appointment, without having to miss lectures.

• The practice was proactive at encouraging chlamydia screening. Staff did this initially by giving out free cinema tickets with every completed test, and last year linked it to valentines and gave out a box of chocolate. The patients screened during these promotions increased the diagnostic rate of chlamydia.

• A GP found there was little support for clinicians to support transgender patients. As a result, they wrote a prescribing and pathways guidance document for the practice and this has been taken up by two CCGs.

• In collaboration with a multi-disciplinary mental health team, patient groups and the student’s union, a weekly drop in session was trialled to signpost and provide brief interventions for patients with mild to moderate eating disorders. The ‘Eating and Emotions’ clinic proved successful and provided the evidence which the practice required to submit a successful application for

innovation funds from the CCG. The service was expanded into both a weekly drop-in, and a series of six CBT based sessions specifically for students. The inclusion of Nottingham Trent University recognised it was a condition across both universities in Nottingham. The scheme has been positively evaluated by The University of Leicester and is being re-procured on an ongoing basis.

• An in-house referral system for musculoskeletal and sports injuries was run by two Sports Medicine qualified GPs. This allowed patients access to a service they would otherwise enter a waiting list following a referral and ensures the GPs remain proficient.

• There was an acupuncture clinic run at the clinic by two GPs and this service is now contracted as part of the pain management referral system for the CCG and available to non-registered patients.

• The practice operated as a ‘C-card’ distribution centre, offering free condoms to patients under 25 once they are registered with the service. Following feedback form mature students on the PPG the they successfully requested funding from the CCG to create an inhouse ‘C-card+’ scheme for older patients. They could collect free packets of 12 condoms form the reception or a

pick-up point within the student’s union.

• There was a in house dermatology service led by a GP with a special interest in dermatology. Although it was initially funded by the CCG it has continued since the funding lapsed at a cost to the practice due to the benefits to the patients. A nurse led acne service was also run by the nursing team during any routine appointment and overseen by the GP with an interest in

Dermatology.

• Due to the large number of students travelling as part of their study or during holidays, a specialist service for travel and tropical medicine was developed. Patients were seen, often at short notice, to ensure they are properly protected. This service is run for both registered, and non-registered patients.

• The practice was keen to support pregnant women and new parents, many of whom are registered at the practice from outside the UK. Staff have developed strong links with the local Sure Start Centres and local organisations to reduce the likelihood of isolation. In conjunction with another Nottingham practice, staff have developed a guide for parents which was locally relevant and explained the services such as walk in centres, ED, and urgent care and included simple guides to common childhood illness. Following a bid for funds from the CCG, 35000 copies of the

guide have been distributed to practices locally as well as health visiting teams and leisure centres. It was well received and available online in several languages.

• The practice worked closely with Community Child and Adolescent Mental Health Service (CAMHS) and monitored the transition to adult mental health teams to ensure care continued to be provided during their time at the university.

• Following feedback, the practice has reduced the turnaround for the majority of repeat prescriptions from 48 to 24 hours.

• The practice has extended its ‘books on prescription’ service from the initial three libraries to all seven. It includes books on topics such as mental health, bad backs and sexual health and is used to provide consistent information for patients to manage their own condition, in addition to the usual care.

• An online registration system has been launched to enable students to register with the practice 24 hours a day and in collaboration with the university students who did not register during the Freshers Event are encouraged to use the online form.

We rated the practice as outstanding for providing well led services because:

• The practice sought feedback from the practice population with a patient participation group, links to the international office, and student’s union. Patients were encouraged to feedback to a ‘tell Dan’ comments box as well as the friends and family test. The practice responded to comments on NHS choices website and used the feedback to praise staff or as learning to drive change.

• As part of ongoing support to staff, the practice signed a charter for employers as a mindful employer’. A GP, who was a clinical fellow in the healthcare professional wellbeing and midlands clinical lead for GP health, was the wellbeing lead. Changes implemented included:

▪ A number of nursing and administration staff had started a positivity working group to look at small changes which could be made across the practiced to improve team health and wellbeing.

▪ The practice had started to facilitate a masseur who provided massages to practice staff on site during the day.

Staff Tai-Chi sessions took place in the garden area during lunch breaks.

▪ There was a doctors ‘peer support group’ who meet every six weeks in the evening and discuss clinical cases, go for a walk in the grounds or do yoga.

▪ A mindfulness session is held at the start of all clinical and staff meetings.

▪ A ‘Nice Event Recording Document’ (NERD) award and staff member of the month were developed to encourage colleagues to show appreciation to each other in a structured way with quarterly prizes being awarded.

• Team meetings were a regular feature on the team’s calendars. This improved decision making and helped facilitate communication. These included:

▪ Weekly meetings of the management team where current issues were discussed and opportunities for service improvement highlighted.

▪ Monthly CPR Thursdays were lunchtime drop in sessions to allow health centre staff (both employed and local practices) to access high quality CPR and BLS training.

▪ Weekly lunchtime meetings with doctors and the management team to discuss current issues,

complaints and significant events. External agencies were invited to these meetings as well as all staff. To encourage uptake, lunch was provided and a range of topics planned for each one in advance, so staff could use it as continued professional development.

• Staff were working with the University on projects such as a health and wellbeing strategy and a separate working group on suicide prevention.

• The practice was a regional leadership site for research in the East Midlands Primary Care Clinical Research Network. This included participating in 15 studies a year and providing guidance on to researchers looking to place new studies in primary care. Four practices were also mentored by the practice research team and they held bi-annual meetings to discuss experiences and

share good practice.

We rated the practice as good for providing safe

services because:

• The practice was proactive in the approach to managing risk. Learning from significant events, audits and complaints was reviewed at weekly and monthly meetings to ensure identified changes were introduced and effective.

• Safeguarding was a standing item on all formal meetings and regular training sessions were run to ensure staff considered safeguarding correctly.

We rated the practice as good for providing effective services because:

• The practice continued to use QOF as a means of reviewing patients with long term conditions, even though in several indicators the numbers of patients meant that the income was low represented against the amount of work involved.

• There was a comprehensive audit schedule and nurses took part in audits as well as GPs

We rated the practice as good for providing caring services because:

• All patients were offered a chaperone and all staff who were chaperones had undergone training to ensure they understood the role.

• Staff worked closely with the pastoral and counselling service of the University to ensure positive outcomes for patients.

Whilst we found no breaches of regulations, the provider should:

• Increase the uptake for national screening programs including cervical cancer screening.

• Continue to work on identifying carer within new registrations and current patients.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated

Care

We carried out an announced comprehensive inspection at the University of Nottingham Health Service on 18 June 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for providing effective, responsive and well led services. It was also outstanding for providing services for older people, people with long term conditions, families, children and young people, working age people and those recently retired, and people experiencing mental health.

The practice was good for providing safe and caring services. It was also good for providing services for people whose circumstances may make them vulnerable.

Our key findings across all the areas we inspected were as follows:

• The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with staff. There was a genuine commitment to continually evolve and improve services for the patients registered at the practice.
• The practice had a strong commitment to learning and improving from internal and external incidents. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• The practice worked closely with other organisations and the local community in planning how services were provided to ensure that they promoted person centred and coordinated care.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice was dedicated to supporting pilot projects and research within primary care and was supported by the clinical commissioning group (CCG) to provide mentoring to other practices interested in becoming accredited for research.
• Information was provided to help patients understand the care available to them in formats they were comfortable with and used extensively. This included the use of social media, facebook, twitter, you tube videos as well as mobile phone health applications.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had a robust triage and appointment system which enabled patients to access the right care at the time. Urgent appointments were available on the same day.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG).
• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.

We saw several areas of outstanding practice including:

• The practice had excellent access to appointments and could demonstrate the impact of this by reduced use of secondary care services (specifically accident and emergency) and positive patient survey results.

Data showed 100% of patients could get through easily to the surgery by phone and the last appointment they got was convenient. This was above local and national averages.  Additionally, the practice patients were the second lowest user of A&E services in the county and the lowest in the CCG according to E- Healthscope data.

• The leadership team and the practice had won several national and local awards in recognition of their innovative approaches to delivering high quality care.

For example, an in-house musculoskeletal, physio and sports medicine service was developed in response to sports injuries linked to the student population and a dermatology and nurse led acne service was offered and funded by the practice at an additional cost to them. This allowed patients to access local services within the community reducing a burden on secondary care or travelling distance for patients.

• We saw excellent examples that demonstrated the practice was fully committed to working in partnership with the University of Nottingham and other health and social care providers to address the social and emotional needs of their patients’ and families. Specifically, the practice took a proactive role in multi-disciplinary working and undertaking education and research linked to improving the well-being of patients experiencing poor mental health.

For example, as part of an innovative pilot, the practice offered a weekly drop in clinic to signpost and provide brief interventions for patients with mild to moderate eating disorders; and a series of six sessions of cognitive behaviour therapy (CBT) specifically for students.

This service was extended to another local university and is currently provided as part of the eating disorders in students service (EDISS). The practice won a national award in recognition of the work involved in commissioning this service.

• In conjunction with the University of Nottingham and Public Health England, the practice undertook a two year study on the mental health needs of international students specifically Chinese and Malaysian students. The findings were presented at a number of conferences across the UK and recommended changes to service provision including complementary culturally based services.

• The practice proactively promoted patient education and control over their care needs through the use of social media and written literature.

Examples included access to a series of You-tube short videos offering instructions on self-management techniques; designing and implementing the NHS Nottingham City Health application: a guide to choosing the right NHS service locally; as well as adapting booklet guides (in collaboration with another provider) to include information on local health services and when to access them and on common childhood illnesses. Over 30,000 copies were distributed to local practices, health visiting teams, maternity units, libraries and leisure centres. The guides are also available online and in several languages.

• The practice had various systems in place to engage and communicate with its student population including: a personalised feedback system named “Tell Dan” whereby the practice manager encouraged direct patient feedback to him and an automated text and email messaging service to allow a fast and easy stream of communication.
• The practice was proactive in its approaches to sexual health screening and prevention in collaboration with the University of Nottingham, CCG and Public Health. For example, a level two sexual health clinic was offered which is similar to that of a genito-urinary medicine (GUM) community clinic.

Services were for symptomatic patients and included treatment and contact tracing for gonorrhoea; cryotherapy for genital warts; c-card registration, pregnancy testing and contraception counselling. Patient feedback and data confirmed these initiatives made a positive impact including promoting patient self-management and disease prevention.