Archived: York Street Health Practice

Updated 20 December 2016

York Street Health Practice is a member of Leeds South and East Clinical Commissioning Group. The provider of the service is Leeds Community Healthcare Trust (LCHT). Alternative Provider Medical Services (APMS) are provided under a contract with NHS England. This is a locally negotiated contract which allows NHS England to contract services from non-NHS bodies. The practice are also a member of Pathway (a UK homeless healthcare charity); a group of organisations who specifically work with and support people who are homeless.

The practice does not participate in the Quality and Outcomes Framework (QOF). (QOF is a voluntary incentive scheme for GP practices in the UK, which financially rewards practices for the management of some of the most common long term conditions.) However, the practice has its own Key Performance Indicators (KPIs) which are submitted on a quarterly and annual basis to their provider LCHT.

The practice provides a range of primary care services for:

• homeless people
• people in temporary or unstable accommodation
• refugees or those seeking asylum
• street-based sex workers
• people who find it hard to access the health care and support they need due to chaotic and complex lifestyles

The staff worked closely with other organisations and with the local community in ensuring bespoke services are provided to meet patients’ needs. The Homeless Admissions Leeds Pathway (HALP) is operated under York Street Health Practice in partnership with St George’s Crypt Homeless Hostel (a charity in the centre of Leeds who work with the homeless and vulnerable and can provide intermediate care beds). The practice had negotiated to have access to three beds there where patients who are in urgent need can be sent.

Patients are often referred to the practice by other agencies or identified through hospital admissions, prison release or word of mouth. In addition, those people seeking asylum status or refugees are also registered. The practice has close links with refugee camps in Syria and the identification of those refugees who are suitable to arrive in Leeds is undertaken in conjunction with the Home Office.

At the time of inspection there were 1,315 patients registered with York Street Health Practice (1,083 male and 232 female). Due to the transient nature of this patient group the practice experiences a high turnover of registered patients, with 15 to 20 new registrations per week. Over 61% of the patient population are homeless and 31% are asylum seekers/refugees. The majority of patients are in the 26 to 65 years age range; with 4% under 18 years of age, 13% aged between 18 and 25 and 1% aged over 65. There is a mixed ethnicity of patients, including white British, African, Asian and Syrian.

The practice is open from 8.30am to 6pm on Monday, Tuesday and Friday. On Wednesday and Thursday the opening times are 9am to 5pm. Patients can access appointments and clinicians during these times. The practice is closed daily between 1.30pm and 2pm to enable all staff to attend a daily meeting known as the ‘huddle’. In addition, there is open access to clinicians and patients can be seen outside of the practice as befit their needs. When the practice is closed the telephones are directed to local care direct. We were informed that due to restrictions in their provider contract, they were unable to offer extended hours access. However, outreach and night services are operated, where clinicians engage with members in the community, such as the homeless or sex workers, who may or may not be registered with the practice.

Updated 20 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at York Street Health Practice on 20 October 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. Six monthly thematic reviews of reported incidents were undertaken and actions identified to minimise reoccurrence.
• All staff attended a daily ‘huddle’ meeting to discuss any issues which had arisen in the 24 hours preceding the meeting and to review and action any outstanding issues. We saw evidence of minutes from meetings and an up-to-date and ongoing action log.
• There were comprehensive safeguarding systems in place to enable staff to identify any areas of concern, act upon them in a timely manner and protect patients and staff from abuse. All clinical staff had formal safeguarding supervision with a member of the local safeguarding team on a regular basis.
• The practice actively reviewed complaints and how they were managed and responded to. There was open access to the practice manager where complaints could be dealt with as they arose.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Patients’ emotional and social needs were seen as equally important as their physical needs. Patients said they were treated with compassion, dignity and respect.
• There was wide-ranging evidence of multi-agency working, where the practice worked closely with other organisations, such as outreach services, refugee councils and homeless shelters, in ensuring services were provided to meet patients’ needs. We received numerous extremely positive testimonials to support this.
• The practice had regular liaison with the Home Office and refugee camps to ensure there was a cohesive approach and the refugee/asylum seekers had timely access to care and support.
• The practice had strong and visible leadership and governance arrangements in place. Staff said felt very supported by management and the team as a whole and there were supportive mechanisms in place. All staff had access to a psychologist once a month and counselling sessions were available as needed. Staff were supported to attend mindfulness courses.
• There was 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:

• There were comprehensive systems in place to support safe practice. The whole team was engaged in reviewing and improving safety and safeguarding systems. The review of all incidents and the learning which arose from those was shared with their provider and external agencies, depending on the appropriateness and confidentiality aspects. There was an ongoing ‘RAG rated’ action plan used to capture and ensure all issues or status reports were discussed or actioned at all meetings. (RAG is a system based on Red, Amber and Green colours used to rate issues.)

• Staff were motivated and inspired to offer kind and compassionate care. For example, they provided suitable clothing for children and adults, food parcels, Christmas gifts, paid for transport for patients to attend appointments and raised money to aid patients as needed. The practice had won several awards for the delivery of compassionate care. Most recently, as part of the Pathway Group of organisations who provide services for homeless people, they had recently received the ‘2016 Kate Granger award for delivering outstanding compassionate care’.
• The practice delivered weekly outreach sessions for the homeless. Twice a month clinicians worked through the night, to provide access to health care and support for street sex workers.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 20 December 2016

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

• We were informed that many of the patients were not always in a position to manage their long term conditions until some stability had been achieved in their lives. Health advice and support was given by all clinicians to patients, taking into account their individual life circumstances. Patients had personalised care planning suitable to their needs.
• Patients at the practice presented with high levels of lung, liver and kidney disease. These could be linked to issues such as poor diet, alcohol and drug misuse. Staff had specific competencies in these areas and were able to support patients accordingly.
• There was an experienced nursing team who provided specialist wound care for venous ulcerations.
• Blood borne virus screening was undertaken. The practice had good liaison with the viral hepatology teams to improvement engagement of patients for Hepatitis C treatment.

Updated 20 December 2016

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

• The practice currently had 61 patients who were under the age of 18 years. This population group fluctuated dependant on the numbers of UNHCR refugees allocated to the practice. It was acknowledged that this group of patients were particularly vulnerable.
• There were clear systems in place to identify and follow up children and families living in disadvantaged circumstances and who were at risk. For example, those females at risk of female genital mutilation (FGM) or human trafficking.
• There was a child safeguarding lead and a process in place to review all patient records for those aged under 18, in order to highlight and act on any safeguarding issues.
• There was a named health visitor attached to the practice to ensure continuity of care for families and young children.
• There was a separate waiting area for families with small children or for patients who were distressed.

Updated 20 December 2016

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

• Compared to other practices, they had a small number of registered patients who were over the age of 65 years. However, proactive, responsive and personalised care was provided to meet the needs of these patients.
• Reviews of care were undertaken and any concerns were discussed at the daily ‘huddle’.
• The practice worked with other agencies, such as outreach and homeless services, to support the needs of these patients
• In liaison with the local palliative care team, end of life care was provided for individuals as needed.
• Influenza and pneumococcal vaccinations were offered to everyone in this population group.

Updated 20 December 2016

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

• Over 90% of patients were noted to be of working age but there was a very high unemployment rate. This group included the homeless, asylum seekers and refugees.
• Flexible services were provided for these patients. For example, outreach services were provided on the streets, both during the day and night to enable patients to access clinicians.
• The practice supported people who were sleeping rough and could offer them temporary shelter through dedicated beds they had at a charitable homeless hostel based in Leeds centre.
• Patients were provided with flexible care and support to meet their individual needs. Health promotion and screening were offered opportunistically.

Updated 20 December 2016

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia).

• The practice had no known patients who had dementia, however, they had high levels of patients who experienced mental ill health or psychological distress and treated them as appropriate.
• Staff had a good understanding of how to support patients with mental health needs and consistently worked with multidisciplinary teams in the case management of these patients. They also worked closely with teams providing support through counselling and psychological therapies.
• Patients were actively assisted to access various support groups and organisations, including social and housing support.
• The practice employed a full time mental health nurse who had professional experience of working with patients who had complex needs. They arranged to see those patients who were most likely to not attend an appointment, outside of the practice environment, such as a coffee shop, to support their health needs.
• 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 or were vulnerable. These patients were discussed in the daily ‘huddle’ meetings and care plans updated.

Updated 20 December 2016

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

• The practice held a register of patients living in vulnerable circumstances including homeless people, gypsy travellers and those with a learning disability.
• The practice offered longer appointments for patients who needed them.
• The practice worked consistently, proactively and sensitively with multidisciplinary teams and other agencies, such refugee councils, homeless charities and poverty services, in the case management of vulnerable patients.
• Through their outreach sessions, the clinicians provided support and care in areas where homeless people were known to gather.
• Those people who were identified as being vulnerable and who were not registered with a GP were referred to York Street Health Practice by other agencies.
• The practice worked closely with local substance misuse services to support patients to access treatments as befitted their needs.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. They had a comprehensive understanding of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
• Staff had attended training sessions on FGM awareness and trafficking. They could demonstrate a good understanding and awareness of how to approach those at risk. There was evidence of working alongside other agencies to identify and support those patients as befit their needs.