St Michael's Surgery

Updated 6 June 2016

St Michael’s Surgery is located in the city of Bath in an area called Twerton with a branch called the Beehive Surgery in the Southdown area of Bath.

The practice population consists of approximately 7,500 patients. The practice population is an outlier in deprivation with many examples of health inequalities including, lower life expectancy than the national average, low rates of employment, low rates of income, poor access to transport and high numbers of multiple health problems. The practice deprivation index of 27.9% is significantly higher than the average for the Bath and North East Somerset region of 12% and the national average of 21.5%.

The practice was working with the local health and care communities and agencies to try to redirect resources to those who need them. The practice had highlighted its health inequalities to the clinical commissioning group to try to meet these needs, and had developed a strategy to address these issues where possible including securing additional funding for two years.

The practice had recently undergone significant changes as the GP partner cover had unexpectedly reduced at short notice over the previous few months and a new practice manager had taken on the role two weeks before our visit.

The practice has noted changing demographics, which although remains mostly white British, now includes some refugee families, some Eastern European families and increasing numbers of ethnic minorities.

The practice has six GP partners, three female and three male, two are due to retire in June 2016. The practice is supported by two salaried GPs and is currently supporting two GP Registrars (Registrars are qualified doctors who undertake additional training to gain experience and higher qualifications in general practice and family medicine).

The GPs are supported by one advanced nurse practitioner, three nursing sisters, one health care assistant and supporting management, reception and administration staff.

The practice is open between 8am and 6pm Monday to Friday. Appointments were from 9am to 11.30am and from 2.50pm to 5.30pm daily. Extended hours appointments were offered one evening a week at St Michael’s surgery from 6.20m to 7pm and at least one evening a month at the Beehive Surgery from 6pm to 7.30pm. Extended hours were also available from 8.10am to 11.20am every other Saturday.

When the practice is closed the out of hours cover is provided by Bath Doctors Urgent Care accessed via NHS 111. The Bath and North East Somerset area have a local agreement with Bath Doctors Urgent Care for the out of hour’s provision to start at 6pm.

The practice has a Primary Medical Services (PMS) contract to deliver health care services. This contract acts as the basis for arrangements between the NHS Commissioning Board and providers of general medical services in England.

The registered activities the practice provides are available at:

St Michael’s Surgery

Walwyn close

Twerton

Bath

BA2 1ER

and

The Beehive Surgery

Mount Road

Southdown

Bath

BA2 1NH

Updated 6 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Michael’s Surgery on 13 April 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting, recording and learning from significant events.
• The practice population has high levels of social deprivation with many examples of health inequalities including high numbers of multiple health problems. The practice deprivation index of 27.9% is significantly higher than the average for the Bath and North East Somerset region of 12% and the national average of 21.5%. The practice was working with the local health and care communities and agencies to try to redirect resources to those who need them.
• 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.
• Services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility and continuity of care.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The practice recognised that the majority of its population accessed care in an unplanned way, and ensured opportunistic access, a high proportion of on the day appointments, and flexible services to meet the patient’s needs.
• The practice had recently undergone significant changes as the GP partner cover had unexpectedly reduced at short notice over the previous few months and a new practice manager had taken on the role two weeks before our visit. The practice staff were working together to review and update processes and procedures, and the practice was in the process of recuiting a new GP partner.
• Although there had been recent changes to the practice in the previous months, the practice reported a clear leadership structure and staff told us they felt supported by the management and that they valued the team and good communication within the practice.

• Risks to patients were assessed and well managed, although some policies were due to be reviewed.

• 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.
• The practice proactively sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

The practice had identified a need to improve care for patients with a borderline personality disorder, they developed a template/pathway guide which had been shared across the local area.

The area the provider should make improvement:

Ensure all staff receive regular appraisals and confirmation of the completion of mandatory training requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 6 June 2016

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

The practice population has an incidence of multiple concurrent health problems in patients occurring (on average) 15 years younger than the national average. This means there is an increased demand on health services from this population. For example, the practice has higher than the national average of patients with diabetes 6.5% compared to the clinical commissioning group average of 4.6%.

This year’s exception reporting figures 2015/16 were significantly lower, for example dementia had reduced from 23.6% to 11.4%, COPD from 26% to 21% and the figures for cancer were now 2% below the clinical commissioning group average.

Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

Performance for diabetes related indicators were higher than the national averages:

• The percentage of patients with diabetes, on the register, in whom the blood test was in the target range in the preceding 12 months (2014/15), was 91% which was higher than the national average of 78%.

• The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months, 2014/15) was in the target range was 88% which was higher than the national average of 78%.

• The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March (2014/15) was 100% which was higher than the national average of 94%.

  The percentage of patients with COPD (chronic obstructive pulmonary disease – a range of chronic lung conditions) who had a review undertaken including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months (2014/15) was 96% which was higher than the national average of 90%.

• Longer appointments and home visits were available when needed.

• Patients with long term conditions 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 6 June 2016

The practice is rated as outstanding for the care of families, children and young people.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
• The practice tailored the immunisation clinics to ensure the maximum uptake for young children, for example opportunistic appointments and a set day clinic to ensure all who attended on the day would be treated.
• The practice had a number of families new to the area from countries where previous immunisation records could not be established. The practice worked with best practice clinical guidelines and the relevant agencies, ensuring the correct immunisation programmes were then in place.
• The practice had higher levels than the local and national averages for children on enhanced care plans. The practice worked with the relevant agencies to coordinate multidisciplinary care for these patients.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
• The percentage of uptake for the cervical screening programme in the last five years was 95% which was significantly higher than the national average of 82%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives and health visitors.

Updated 6 June 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• The practice worked with the local hospital and community multidisciplinary teams to directly support patients in step down beds to support earlier discharge from hospital.

Updated 6 June 2016

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, those recently retired and students 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 online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• The practice offered extended hours appointments and telephone consultations.

Updated 6 June 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). The practice had higher than the local and national averages of patients with complex mental health needs, for example 9% of the population with long term mental health problems compared to the clinical commissioning group average of 4.5% and the England average of 4.6%. The practice had analysed the needs of this group and noted higher than average incidence of reduced social and family support, reduced ability to manage self-care, and that many patients struggled with their care being shared across a range of health services. The practice had adjusted appointments to ensure longer appointment times, and that the patient’s whole care needs were managed alongside their mental health needs where possible.

• The practice had developed a borderline personality disorder pathway which had been shared across the local area.

• The practice offered talking therapies counselling, drop in clinics and a range of support services to patients with complex mental health needs. The practice recognised that some aspects of patients’ lives could be unplanned and all these patients would be seen opportunistically where possible.

• The percentage of patients with a serious mental health who have a comprehensive, agreed care plan documented in their record, in the preceding 12 months (2014/15) was 91% which was higher than the national average of 88%.

• The percentage of patients with a serious mental health problem whose alcohol consumption has been recorded in the preceding12 months (2014/15) was 89% which was comparable to the national average of 90%.

• The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the preceding 12 months (2014/15) was 85% which was comparable to the national percentage of 84%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

• 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 and dementia.

Updated 6 June 2016

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

The practice worked proactively to identified any patients who may be in need of any extra support, and regularly reviewed patients social, emotional and financial circumstances alongside the medical care needs to ensure the best care advice and pathways were in place.

• The practice ran a drop in clinic for anyone who may be at risk of, or experiencing domestic violence.

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

• The practice supported four times the national average of patients with learning difficulties and offered longer appointments for patients with a learning disability. The practice worked with advocates, keyworkers and other agencies to provide the best care pathways were in place. 86% of patients with a learning disability had had their care reviewed in the last 12 months, and the remaining 14% had a review scheduled.

• The practice had approximately 60 patients with learning difficulties that are female and need routine cervical smears. They worked with advocates, keyworkers and the patients to ensure each case was individually reviewed and the most appropriate treatment was delivered.

• The practice offered longer and opportunistic appointments for those with complex health and /or social needs.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice provided counselling support, alcohol and drug support on site and 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.