Whitstable Medical Practice

Updated 21 April 2016

Whitstable Medical Practice is a GP practice located in the town of Whitstable Kent. It provides care for approximately 35000 patients. The practice is in a predominantly urban area.

There are 15 GP partners and five salaried GPs. There are 31 practice nurses, with varying qualifications such as Advanced Nurse Practitioners and nurse prescribers, supported by a team of healthcare assistants.

The age of the population the practice serves is close to the national average for patients up to 64 years of age. There are 46% more patients aged between 65 and 75 years than the national average. There are nearly 50% more patients aged between 75 and 85 years than the national average. There are 64% more patients over 85 years than the national average.

Income deprivation and unemployment are low both being about two thirds of the national figure.

In March 2015 Whitstable medical practice was one of three local founding practices to become a Vanguard site. Vanguard sites are being developed as part of implementing the NHS Five Year Forward View. Part of the objective is to support improvement and integration of services. Whitstable’s particular Vanguard site is called Encompass. On its launch it covered a practice population of some 53,000 patients but has since expanded to cover about 170,000 patients. It is a partnership with local health, care and support organisations including Canterbury & Coastal CCG, Kent County Council, East Kent Hospital University Foundation Trust, Kent Community Health NHS Foundation Trust, Kent Partnership Trust and AgeUK. However this report deals with the services provided by the Whitstable Medical Practice in its own right.

The practice has a personal medical services (PMS) contract with NHS England for delivering primary care services to local communities. The practice also offers a wide range of other services under a number of different contract types. The practice is a teaching practice teaching trainee doctors, nurse, paramedics and medical students. It is a training practice, providing training for qualified doctors to become GPs.

The practice is open between 8.00am and 6.30pm Monday to Friday. There are regular extended hours surgeries between 7am and 8am and 6.30pm and 7.30pm. The practice runs a minor injuries unit, patients can be seen there between 8am and 8pm 365 days of the year.

The practice has three purpose built healthcare centres within the town namely:

Estuary View Medical Centre

Boorman Way

WhitstableCT5 3SE

01227 284300

Whitstable Health Centre

Harbour Street

WhitstableCT5 1BZ

01227 284320

Chestfield Medical Centre

Reeves Way

ChestfieldCT5 3QU

01227 795130

We visited all three sites in the course of the inspection.

The practice has opted out of providing out-of-hours services to their own patients. This is provided by Integrated Care 24 Ltd. There is information, on the practice buildings and website, for patients on how to access the out of hours service when the practice is closed.

Updated 21 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Whitstable Medical Practice on 21 January 2016.Overall the practice is rated as outstanding.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. There was a very wide range of services, clinical and non-clinical. The practice was a Multi-speciality Community Provider with an ethos to bring services to the patient rather sending patients to the service.

• Feedback from patients about their care was consistently and strongly positive.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. The practice was part of a Vanguard site combining with other providers to deliver services across a substantial area of East Kent.

• 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. For example walk-in surgeries and changes to the telephone response times and methods of calling patients by telephone
• 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.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

We saw several areas of outstanding practice including:

• The practice had been effective in reducing the number of unplanned admissions to hospital for patients over 74 years. There was evidence to support that this was linked to the practice’s initiative to a provide paramedic practitioner home visit service across the area.

• The practice had a Patient Safety and Quality Manager who was responsible for ensuring that there was a thorough analysis of the significant events.

• The practice sponsored and supported a dementia café at one of their practice sites and was developing a similar café at a second site. Here people, patients and carers, with problems related to dementia, had their emotional and social needs met as well as addressing health issues.

• The practice was trialling social prescribing with local volunteer organisations as a means of directing vulnerable patients to non-clinical services that support social, emotional or practical needs.

• The practice had played a leading role in the formation and growth of the Encompass vanguard site across a substantial region of East Kent, enhancing the range and increasing the ease of access to services. This was consistent with the practice’s objective was to place the patients at the heart of the services, rather than the patients being sent round the health care system to access the services.

• Patients with complex or multiple needs were managed through integrated patient centred services, and were able to access services which would otherwise be up to an hour and a half away.

• It had a scheme for nursing and residential homes where an individual GP took responsibility. There were regular multi-disciplinary team meetings, which included a consultant geriatrician, relatives were routinely invited.

• The practice staff had undergone a number of innovative training events designed to increase staff interpersonal skills. There had been a role play workshop using actors to help improve GPs communication with patients. This was intended to reduce complaints and complaints had been reduced. The practice was involved in training at many levels and showed that as a practice they were as keen to learn from trainees as they were to teach them.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients with long-term conditions.

There were 10 members of the nursing team who were qualified to look after patients with long term conditions (LTC). There were GPs with special interests (GpwSI) in epilepsy, diabetes, cardiology, dermatology and respiratory medicine. A GP with a Special Interest (GPwSI) supplements their role as a generalist by providing an additional specialist service while still working in the community. This range of specialties allowed GPs and nurses within the Practice to get immediate access to expert advice without the need for the patient to wait for a secondary care appointment.

There were clinics for patients with asthma, chronic obstructive pulmonary disease (COPD), diabetes, coronary heart disease and hypertension. In house diagnostics have much reduced the number of visits that this group of patients would normally have to make to the local general district hospital.

QOF results for patients with LTC were generally better than nationally though there were some variations.

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of families, children and young people.

There were systems to identify and follow up children living in disadvantaged circumstances for example, children and young people who had a high number of A&E attendances or those on the local authority “at risk” register. There were positive examples of joint working with midwives, health visitors and school nurses. For example children and families at risk were discussed at a monthly meeting with health visitors.

Immunisation rates for children under five years were similar to the national averages. For one year old children the rates were generally better than the national averages.

Appointments were available outside of school hours and, in particular, clinic times were varied across the week to help ensure that families and children could attend at a convenient time. The premises were suitable for children and babies and there were changing facilities.

The walk-in surgeries from 8am to 11am were popular with families as they knew they would be seen by a GP. Patients we spoke with said that this was much easier than trying to ring in hope of getting an appointment whist trying to get children ready for school.

There was a children’s notice board at each site that informed parents of the services and clinics available at the local children’s centres. These were kept up to date by the health visitor team.

The practice wrote to patients when they became 16 years old, to check their details and particularly to ensure that the practice had the right mobile telephone number, used for notifying patients by text message.

There were collection points in the patient toilets for Chlamydia testing kits as the practice recognised that the kits are more likely to be taken by young people in a private setting. The practice had introduced telephone slots for family planning trained nurses to contact patients who might have questions and find it difficult to attend the surgery or who preferred to ask questions over the telephone. The practice had found that this was of most benefit to young mothers, those of working age and young people.

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of older patients.

The practice offered proactive, personalised care to meet the needs of the older people in its population. It had a scheme for all the nursing and residential homes in the practice area. This involved registering all the patients (with their consent) with one GP who looked after that home. There was better continuity of care, weekly ward rounds and better communication with the care workers. Relatives were invited to attend routine joint visits by a multidisciplinary team that included the GP, a consultant geriatrician, the medicines management and community nursing teams. The aim of this was to improve and to personalise the care of elderly patients. All these patients now have anticipatory care plans and advanced directives in place where appropriate.

Two members of the reception team had, on their own initiative, been trained to undertake simple hearing aid repairs. They provided a continuous walk-in service. This reduced the time these, mostly older, patients were without their hearing aids and reduced the incidence of isolation.

Many of the clinics provided, such as cataract surgery, echocardiography, ultrasound, dermatology, fracture and x-ray were of particular benefit to the older patients. All these clinics were available on a Saturday so that working relatives found it easier to accompany these patients.

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding 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 encouraged this group to take part in practice surveys, by the survey being available through text messaging. Patients who took part were informed, through the phrasing of the questions about current appointment systems, ways of ordering prescriptions and how to use the on-line appointment booking, prescription requests and other services through the ‘Patient Access’ system. The survey also alerted them to the existence of the patient participation group (PPG) and the quarterly patient newsletter.

There was a range of extended hours surgeries available. The practice varied the times of clinics throughout the week to provide the best opportunity for this group to access the services at a time convenient to them. Many of the clinics provided, such as cataract surgery, echocardiography, ultrasound, dermatology, fracture and x-ray were available on a Saturday. This often allowed carers, many of whom are from the working age population, to accompany patients to these appointments.

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients experiencing poor mental health (including people with dementia).

Of those patients diagnosed with dementia, 80% had had their care reviewed in a face to face meeting in the last 12 months. This was in line with the national average (84%). Performance against this QOF target had been erratic over the last five years but generally below average. For a similar QOF target, seeing patients with mental health problems each year the practice had achieved 91% and was better than the national average of 88%. The practice had bettered the national average every year for the last five years.

The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. When a local community venue was closed the practice provided free accommodation to the adult mental health and dementia teams so that these patients would not be forced to travel further to access services. Evidence shows that attendance at clinics and subsequent compliance with medication regimes is increased when clinics are close to where the patients live.

The practice recognised that the majority of the most complex patients were those with mental health problems. The practice had organised a mental health review meeting involving a consultant psychiatrist, community psychiatric nurses, a mental health social worker, and a representative from a local charity to see if such a multidisciplinary team can provide help and guidance on how to manage these patients. The meeting was due shortly after the inspection.

The Practice offered a memory screening programme for patients who felt they were at risk of dementia. The patients could self-refer and it was carried out at each site for the patients’ convenience and in a setting that was familiar to them. Patients were able to self-refer to counselling services. The practice said that this had helped patients with mental health problems to access these services.

A GP at the practice was a GpwSI in epilepsy and some of their clinics were held in the practice to make attendance for these patients easier.

There were two dementia cafes a week held at the Whitstable Health Centre, run by the Friends Group. The practice had plans to hold a dementia café at the Estuary View site. Patients, who attended the cafes, were entering familiar territory when they came for treatment. This is recognised as an important factor in reducing the distress that both mental health and dementia patients feel when being treated in unfamiliar or alien environments.

The practice carried out advance care planning for patients with dementia, sometimes as part of the nursing home initiative.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. The practice used an umbrella organisation to sign post patients to the range of possible interventions in the area. The practice had systems to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Updated 21 April 2016

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients whose circumstances may make them vulnerable.

The Practice had portable hearing loops on all the reception desks. These were then available for use during GPs consultations if the need arose.

The practice had a register of patients living in vulnerable circumstances such as homeless people, patients who may be suffering domestic abuse or those with a learning disability.

The Practice attended the local Multi Agency Risk Assessment Conferences. These occurred every other month and were organised by the police authority. Attendance allowed the practice to identify patients and families at risk of domestic violence. Therefore anyone seeing the patient was alerted, through a flag on the patient record, to the additional problems these patients might be experiencing. There was information about obtaining help and advice on domestic violence available in the patient toilets in recognition of the fact that the victims of abuse are unwilling to be seen noting such information in public.

The practice offered longer appointments for patients with a learning disability. The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

The practice was trialling social prescribing (social prescribing is a means of enabling primary care services to refer patients with social, emotional or practical needs to alternative non clinical interventions) as a means of directing vulnerable patients to various support groups and voluntary organisations. The practice recognised that it was not practicable, nor did it represent value for money, for the practice to be constantly updating lists of support organisations. It therefore used an umbrella organisation to sign post such patients to the range of possible interventions in the area.

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.

Reception staff contacted patients who had difficulty keeping appointments, such as some patients with learning disability or dementia, a few hours before their appointments to try and ensure the appointments were not missed.