Archived: Foundations

Updated 4 April 2017

Situated in an urban area of the North east of England, The Fulcrum medical practice, Acklam road, Middlesbrough, TS5 4EQ provides GP and specialist pharmacological and psychosocial services for those people with addiction to drugs and alcohol. It is served well by public transport links. The practice scores one, on a scale of one to ten, for deprivation. The lower the Indices of Multiple Deprivation (IMD) decile the more deprived an area is. People living in more deprived areas tend to have greater need for health services.

The practice comprises of four partners (a GP, two specialist addictions nurse prescribers and a business manager). In addition to this there are two salaried GPs (one is male, one is female) and a locum GP (male). There are four specialist addictions nurse prescribers (male and female) and six clinical support workers, plus an additional support worker. The non-clinical team comprises of two health improvement assistants, receptionists, admininstrators, data analyists and summarisers.

There are 712 patients registered at the practice. The mean average age of patients registered with the practice is 38 years of age. Of all of the patients registered at Fulcrum, 78% are male and 22% are female. There are only 46 children registered at the practice. Adult patients can only register at the practice if they have a substance misuse problem. For many of the practice population the substance is predominantly heroin. Many patients in their thirties and forties who are registered at the practice exhibit health needs more commonly seen in the older people population group, for example; Chronic Obstructive Pulmonary Disease (COPD), and osteoporosis.

The practice is housed in a large purpose-built premises just a mile from the town centre. There is a pharmacy situated next door.

The practice premises are open from 9am until 6pm on Mondays, Tuesdays, Wednesdays and Fridays. On a Thursday it opens from 12pm until 6pm, and on Saturdays from 9am until 1pm. The practice has a Personal Medical Services contract with NHS England.

Updated 4 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fulcrum medical practice on 25 January 2017. Overall the practice is rated as good.

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

• Risks to patients were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

(The Duty of Candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment.)

The Fulcrum medical practice is a unique primary medical practice in Middlesbrough, which provides GP and specialist pharmacological and psychosocial services for people with addiction to drugs and alcohol. There are 712 patients registered at the practice. The mean average age of patients registered with the practice is 38 years of age. Of all of the patients registered at Fulcrum, 78% are male and 22% are female. There are only 46 children registered at the practice. Adult patients can only register at the practice if they have a substance misuse problem. For many of the practice population the substance is predominantly heroin.

We saw areas of outstanding practice:

• The practice had trained many of its patients how to use a life-saving opiate overdose reversal drug, and provided take-home kits for single patient use. Analysis of data from patient records had indicated how effective this project was in reversing heroin overdose. 325 patients were trained and given take-home kits (a medication to reverse the effects of a heroin overdose) and 71 of these patients had used the life-saving kit in the first few months of the project.

• All patients who attended for their cervical screening received a small pack of toiletries to take away, along with health promotion advice. This had greatly increased the cervical screening uptake rate (by 24%). The practice’s current uptake figure of 81% is above the national average uptake rate of 71%, within mainstream general practices. This is a significant figure in a small cohort of females in a hard-to-reach population group.
• The waiting area had been transformed into a more relaxed informal space, furnished with sofas and comfortable seating. It was used as a therapeutic space to undertake daily health promotion sessions using health promotion specialists capturing a hard to reach group and enabling them to take responsibility for their own health and development.

The areas where the provider should make improvements are:

• Include Infection Prevention and Control as part of the induction programme.

Identify the need for, and monitor the completion of, Mental Capacity Act (2005) training for all clinical staff in order for them to carry out their duties effectively and safely. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 April 2017

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Nationally reported data showed that the percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less was 80%, which was comparable to the England average of 78%.
• Longer appointments were available when needed.
• Patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 4 April 2017

• There were very few patients in this population group (less than 2%). Only 46 children were registered with the practice.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• Immunisation uptake rates in children under five years were 100%
• The practice funded and provided toiletries as incentives for women attending antenatal appointments with the midwife at the practice, and for women attending for cervical screening.
• Cervical screening uptake rates were 10% higher than the national average.

Updated 4 April 2017

• There were very few patients in this population group (less than 1%). The mean average age of patients was 38 years.

The premises were accessible for people with limited mobility.

Updated 4 April 2017

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The needs of the working age population had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• The practice was proactive in offering a full range of health promotion and screening that reflects the needs for this age group.
• Saturday morning appointments were available for working-age people.

Updated 4 April 2017

The practice is rated as outstanding for the care of people experiencing poor mental health

• Nationally reported data (2015/2016) showed that the percentage of patients with physical and/or mental health conditions whose notes record smoking status in the preceding 12 months was 96% which is similar to the England average of 95%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff had a good understanding of how to support patients with mental health needs.
• There was ease of access to mental health specialists within the practice, and referrals to community talking therapies were accessible.
• There was ongoing psychological assessment of patients readiness to start detoxification from drugs and/or alcohol.
• Mental health and psychological wellbeing were treated with equal importance to patients’ physical health status.
• The practice constantly evaluated its psychosocial intervention work by asking patients for feedback about sessions.

It used the evaluation to consider themes on how to improve delivery of the sessions.

Updated 4 April 2017

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

• All patients on the practice list were in circumstances which make them vulnerable due to the specialist nature of the GP practice.
• The practice offered longer appointments for all patients who required this.
• Patients could access a GP or nurse without an appointment via an on-call ‘walk-in’ system.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• Patients were able to discuss multiple presenting problems at one appointment.
• There was a dedicated detoxification team who worked flexible hours, at a variety of locations to suit the patient, for example within the patients’ homes or at neutral venues across the town.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
• The practice had close links with social care, via an open dialogue and regular meetings, to keep vulnerable patients safe.
• Patients on opiate substitute medication were trained to administer overdose reversal medication, to reduce the risk of fatal overdose.
• The practice had clear protocols and boundaries about the prescribing of opiate substitute medication.
• Practice derived data indicated that patients registered at the practice were 82% more likely to survive than patients (who used drugs and alcohol) registered with regular GMS providers within the same town.
• The practice delivered health promotion sessions in numerous opportunistic ways, to capture the health needs of a hard to reach group of patients.